David Healy – Polluting Our Internal Environments: The Perils of Polypharmacy

Joining us today for the Mad in America podcast is renowned psychopharmacologist Dr David Healy.

David is a psychiatrist, scientist and author. Before becoming a professor of psychiatry in Wales, and more recently in the Department of Family Medicine at McMaster University in Canada, he studied medicine in Dublin and at Cambridge University.

He is a former Secretary of the British Association for Psychopharmacology and has authored more than 220 peer-reviewed articles and 25 books, including The Antidepressant Era and The Creation of Psychopharmacology and Pharmageddon.

He has been involved as an expert witness in homicide and suicide trials involving psychotropic drugs, and in bringing problems with these drugs to the attention of American and European regulators, as well as raising awareness of how pharmaceutical companies sell drugs by marketing diseases and co-opting academic opinion-leaders, ghost-writing their articles.

David is a founder and CEO of Data Based Medicine Limited, which operates through its website RxISK.org, dedicated to making medicines safer through online direct patient reporting of drug side effects.

In this interview, we discuss the recently held World Tapering Day, a possible relationship between antidepressant treatment and sensory neuropathy and the difficulties that can be encountered when trying to deprescribe.

The transcript below has been edited for length and clarity. Listen to the audio of the interview here.

James Moore: David, welcome. Thank you so much for taking the time to join me again for the Mad in America podcast. It’s good to catch up and explore where your thinking is at with various issues.

David Healy: It’s good to be here and our conversations have always been great. The issues are probably pertinent to some of the stuff that I was looking at recently linked to World Tapering Day. So yes, lots to pick up on.

Moore: As you say, World Tapering Day was held over the 4th, 5th and 6th of November and it was led by people from the Netherlands who, themselves, have experiences with opioid and antidepressant withdrawal and experience supporting people trying to come off the drugs. I just wondered what your reflection was on World Tapering Day and whether it’s a good thing to get people together around a banner such as this.

Healy: I think it was a great thing from a few different points of view. First of all, I think putting the idea of tapering on the map and having tapering strips gives both patients who may want to get off the drugs and doctors who are faced with the question from patients, “how do I get off these drugs?” the idea that there is a way to do it, which makes it easier for people to recognize the problem.

I think a lot of the problems in both mental health and general healthcare become problems because someone comes to the doctor who has no answers and because they’ve got no answers they don’t want to even hear or see the problem. That adds to the problem, the fact that I’m not being seen, I’m not being listened to and not believed. Even if the doctor hasn’t an answer, it’s great to be believed.

Now, if the doctor and the patient have an idea that tapering strips are a way to move this forward, that’s going to encourage them both to take the chance. A lot of people have problems tapering and I’m sure that the strips help, though some people have very severe problems which may not be just as simple as using a strip.

Looking at the World Tapering Day presentations and the videos that are there now, Peter Groot who is the person who got tapering strips off the ground is very impressive. Not in the way of an expert standing up there and saying, “This is the way, the truth and the light,” much more a case of he’s just painfully honest and decent. He kind of talks about the issues and somehow has a way of getting things that need to be on the radar.

Right at the end of his talk, he said things that are all too true, which is that the pharmaceutical companies brought these drugs on the market and they are all one-size-fits-all and they didn’t have doses that we could step down to and make it easy to get off. He didn’t quite use the word evil but he went very close to it, saying that this is a complete scandal. It means that rich people are fine, they can go to compounding pharmacists and pay double or triple the usual costs or they can buy liquids that are much higher costs to help them get off. Most people who are hooked on antidepressants don’t have these options. If the family doctors refuse to actually prescribe a liquid because it’s going to cost them more, or if they go to a compounding pharmacy and hear, “Yes, we can make that up for you but it’s going to cost a lot more,” it really gets people in a bind.

This is an awful problem which affects millions of people and messes up the lives of hundreds of thousands of people. There is no support for the people that are caught in this bind. Peter, as I say, gave a terribly simple talk but fairly profound and he is quite a remarkable man, I think.

Moore: In my dealings with Peter, I’ve always been impressed by what motivated him to do this, the simple motivation of identifying a problem that he could see a practical solution to and trying to help people. So there was never any talk about money or recognition. It really was simply about trying to fix a problem that he saw that affected him and affected others.
While I don’t suggest the strips are the right tool for everybody, they are another tool in the box and the more tools in the box there are, the more proof there is that this is a pressing problem that needs answers. It does give doctors a way to respond to this problem, as you said, if people are believed. That’s a big issue in itself, isn’t it?
There are a number of things, withdrawal, perhaps chronic fatigue or even long-COVID now where as soon as the doctor hears certain phrases, they stop believing that person. That’s quite a challenge to stand up to your doctor to say, “I know more than this about you. I’ve been living with this.”
I wondered what your experience was of that. Is there anything that could be done to get your doctor on board?

Healy: Yes and I’ve been thinking about this a lot, but just to hop back quickly before we go on to getting the doctor on board. One of the other things tapering strips do is even if they are not right for all people, even if—as I think—there’s this group of people who have a sensory neuropathy caused by the drugs and while tapering helps with that, it’s not the complete answer. There are going to be some people that we’re going to have to try and find some way to make the little nerve endings that actually seem to be damaged regrow.
To this day doctors, probably even most of them tell people who want to get off drugs, first of all, there is this group of doctors that say, “You can’t. You have to remain on these for the rest of your life.” That’s a huge group but there is also a group that say to the person, whether that’s an SSRI or a benzodiazepine or whatever, “It’s easy enough, just switch from taking one pill a day to one every two days and then after a few weeks, change one every three days.” This is disastrous. This is very bad advice.

One of the things tapering strips can do, which is good for all people, is to stop doctors saying crazy things like this. I mean, it might sound reasonable to them but we know that it’s just not right and it is actually making things worse.

I have a sense even that people often can’t talk about these things, because the doctor—even though they think he or she is a nice person—may turn nasty and may play the expert card. “I am the expert. When you’ve got 10 years of training in medicine, then we can have a conversation,” or something like that. For me, I’ve learned more from the people who brought problems to me than any of my medical colleagues. Like a lady who taught me that SSRIs can cause you to become alcoholic and told me more about the serotonin system than I knew.

People who have post-SSRI sexual dysfunction (PSSD) are the ones who come up with all of the research ideas, it’s not me, but equally, there is a further thing that people can do for themselves in groups.

I had a patient who actually looks a little bit like you, about the same height, the same build and the same charming manner, who had bad OCD. This was four or five years ago. A nice man who is an electrician and he had OCD. He had to go fix heating. You have to undo a bunch of wires and then put them back in the right place, which is a nightmare if your OCD is acting up. So they take pictures the whole time of how it was before we changed them and then a picture of how things are now after we changed them. If you go home and you’re not sure you did it right, you can look at the picture and try to reassure yourself. Any time I’ve had people come into the house to fix the heating since and I see them take out a phone you can ask them if they have OCD and they’ll often say, “Yes, I do.”

Anyway, this man says his OCD had acted up and he’d been on SSRIs before and we put him on an SSRI and tried clomipramine which is a bit stronger. Through the whole thing, this is just a nice man who is clearly suffering and OCD can cause terrible suffering and my urgency was I had to help him. I was doing everything I could but things didn’t seem to be working out.

One day, he comes back to the clinic and he knows that I like him and I think he should feel free to say anything to me, but he doesn’t. He has to sound things out and decides yes, I’ll try that, I’ll tell Healy what I’ve done. He says, “Look, the OCD got worse when I stopped smoking and I’ve gone back on smoking. What do you know, it’s a lot better.” I am there thinking this is very interesting. He says, “Look, I’ve Googled this and actually, there are clinical trials of smoking and nicotine patches and the drug for Alzheimer’s called Donepezil, which acts a little bit the same way for OCD and there is evidence for these things have on OCD.” So, there is a lot of research that people out there who could be electricians or whatever do and they come up with the right answers.

I actually called British-American Tobacco on the phone and said look, I’m a doctor in a mental health center and I’m treating patients. I’ll be doing some research on smoking and patches and things like that and it looks like smoking can be good for OCD. Do you know anything about this and is there anything you can tell me about this? There was silence at the other end of the phone. They are not used to people telling them that maybe there is a good use for smoking. So they haven’t ever gotten back. They don’t want to go near it.

The other thing is that most people think SSRIs are good safe drugs. They are prescribed by doctors. Doctors wouldn’t tell you to smoke, but nicotine and alcohol are available over the counter and SSRIs are on prescription because we think they are more dangerous than nicotine or alcohol. The other thing, which needs to come into the frame a little bit is most people figure if you smoke consistently for the next 20-30 years, it’s going to shorten your life. If you drink every day for the next 20-30 years, it’s going to shorten your life. I am sure if you take SSRIs and antipsychotics and combine them every day for the next 10 or 20 years, it’s going to shorten your life and cause you to age visibly. It’s one of the things people need to take into account and doctors need to take into account when they put people on these drugs, not just putting them on but we need to be thinking from the start when and how to get them off, which is not happening.

Moore: That is a fascinating story and it reminds me of the ingenuity of the people to try and find any way through their difficulties. Quite often, people are successful in making changes which are far outside the thing they are dealing with but actually have some beneficial ancillary effect.
I’m sure you’ve seen it yourself, if you go on forums for SSRI or antipsychotic withdrawal, there are perennial conversations about up-dosing to try and dampen down symptoms or to go back on to a tiny bit of what you were on in the hope that it might help. Some people do that and they are helped but there is tremendous shame and stigma associated with people saying, “I feel that I haven’t completed my journey. I feel shameful that I’ve had to go back on,” but if it’s an answer for people, it’s an answer. Isn’t it?

Healy: Yes. Peter Groot raised this, which is that tapering strips work, wonderful, but there are some people who aren’t quite right when they get off and it does seem to be the case for some people that if they just go back on the one-milligram dose it can help. Now there are a few curiosities about this.

One of the things to bear in mind is that quite apart from the fact that we don’t have liquid formulations, which is criminal, when the companies brought the SSRIs on the market they were scared they wouldn’t be able to show that they worked. To get through FDA they really figured they needed to give people an awfully high dose. When you take an SSRI, it’s like driving a sports car through a city center. You are in something that is not built for the environment that you’re in. It can go from zero to 100 in two or three seconds, but you are not going to do that in the city center.

From that point of view, Prozac in a five-milligram dose or even a one-milligram dose is close to as effective in clinical trials as the 20-milligram doses, but they figured let’s make things simple for doctors. They weren’t treating doctors like experts, they were just treating doctors like teenage consumers who need it to be kept simple. This is why they brought the one-size-fits-all dose on, which was much too high.

The older antidepressants came in a 100-milligram dose, a 50-milligram dose, a 25-milligram dose, a 10-milligram dose and a liquid, but that all went out the window. So it’s probably the case that going back on a very, very low dose, we don’t quite know how low, can be effective and there are good grounds to think that it will be beneficial. It’s not that you’re on a terribly low dose, you’re on what in many respects is a reasonable dose. The other dose was unreasonable.

Linked into that there is another possibility, which is that for a group of people, life is just not quite right and they need to go back on a low dose. I’m not sure it’s working as an antidepressant at that point. One of my hunches is it’s working to manage sensory neuropathy.

In all of us, we’ve got the big nerves that move a body around the place and things like that. We’ve also got a bunch of little nerves which are in our skin and guts and these have what are called small fiber nerves and they are unprotected. The big nerves have a big sheath around them and if that goes wrong you can have awful problems, but the little nerves don’t have anything. They are exposed and one of the things we know is that a lot of the psychotropic drugs we use, particularly for pain, like the antidepressants and the anticonvulsants actually help ease the pain by killing nerve endings. I think that gives rise to the thing I’m interested in, which is post-SSRI sexual dysfunction, where the genitals go numb because the nerve endings in them have got fried. It’s not a brain problem, it’s a peripheral problem.

This is what I think gives rise to things like brain fog that people complain about. It’s not just the sensory input from the genital area but it’s from around the body, from your gut and so on. Your brain is much more attuned to your gut and bladder and genitals than it is to things happening outside you. So when there is no input, this gives rise to the depersonalization, de-realization, brain fog and things like that. When you’ve got that kind of thing happening, I think what we’ve got is not just a withdrawal problem but it’s revealed a sensory neuropathy problem, which is there in some people but not all.

I have a colleague who is a doctor who reported recently that he was on SSRIs for a few years, he didn’t know he could get hooked to them and he had an awful time trying to withdraw but he was determined. He tapered off them and said, “I am feeling better. There are things I can do now that I couldn’t do on the pills and I was keen to be able to do, but I am not that good. They caused me some harm, some damage,” and then he got in touch with me one day, about four years later and said, “Hey, all of a sudden, just a few weeks ago, everything changed in a very short period of time and I came back to normal. It was as though the lights went on. I was feeling back to me.” Now that’s consistent with nerve-endings regrowing and plugging themselves in and the brain getting a lot more stimulation.

So that’s a little bit of what interests me, but there is another angle and this comes back slightly to the nicotine story and smoking. One of the big myths we have is that you want to avoid too many drugs that have an anticholinergic effect. This idea goes back to the mid-1960s when a thing called the catecholamine hypothesis of depression turned up. We said that in people who are depressed, they’ve got lowered noradrenaline levels or lower norepinephrine, as they say, over in the States. Nobody even mentioned anything about serotonin but the idea was if you’ve got a drug that was a pure norepinephrine reuptake inhibitor and doesn’t do anything else, it’ll work very well and will be free of side effects. Most of these drugs have an anticholinergic effect also and that causes you to be unable to pass water. It causes you to be constipated. It gives you a dry mouth and blurred vision.

Everybody swallowed that, but it’s not true. A lot of patients called into the hospitals say they will be happy enough if you stopped their antipsychotic drug or lowered the dose, but don’t touch my anticholinergic. That’s the one that’s helping me. Now, it’s helping in two or three ways. One is it’s a feel-good pill. You don’t get hooked to it, as far as I know, but you do feel good on them and people in the past used to brew up herbs that were anticholinergic in order to feel good and euphoric. But here is the thing, 10 years ago there were reports that anticholinergic drugs in a low dose can cause small nerve fiber endings to regrow.

We’ve been told to get people off anticholinergic drugs or reduce their anticholinergic burden but in fact, that may do much harm. There is an increasing amount of evidence that it may be possible not just to let these little nerve fibers regrow, which could take months or years, but to actually promote the regrowth so maybe we could get the job done much quicker.

Moore: I have to say, there are a couple of fascinating posts on Rxisk.org about this and the response from readers and their comments back are also interesting. You talked earlier about skin biopsies to see if this kind of damage can be checked for. Should we be going en masse to neurologists to ask for help with withdrawal or sexual dysfunction problems rather than going to a GP who seems largely clueless?

Healy: GPs are awfully good, all things being equal you’ve got a better chance with a GP than you have at a specialist, either mental health, neurology or whatever. They’ve got very boxed in and if the problem you’re having is not totally and directly in their area, they disown it. Whereas a family doctor is more likely to have a slightly broader view and if, as you say, we can turn them around and get them interested to listen and maybe not figure they have to have all the answers themselves but maybe make them more aware that the patient bringing in the problem to them may also have an idea what the answer might be.

If you go in to get off your antidepressants, while I don’t think tapering is the whole answer, a much safer bet is to become an expert on tapering strips. Go and see the World Tapering Day videos and then bring the answer to your doctor who will be there saying, “I don’t know how to do it. I don’t know how to cross you over from this drug to that drug or at what rate to bring you down.” If you can do the work for him or for her, it’s more likely to work out.

As people who go to Rxisk blogs will see, it’s been people with PSSD and I’m sure this is true for withdrawal as well, a lot of them seem to have antibodies to the cholinergic receptors that seem to be linked into all this. Again, this has been driven by the people who have the problem and who’ve got skin in the game. The average doctor hasn’t got skin in the game. So the trick is how to get him to think it was his idea but you were the one who was feeding it to him.

Moore: You also mentioned in that blog and I can’t remember the exact wording but you talk about tapering revealing a problem rather than causing it. So, again, many people in forums will say, “I didn’t start to suffer until I tapered. So that must mean I tapered the wrong way,” and they blame themselves. So the question is, did the way they tapered cause their problem or would that problem have arisen no matter how they tapered? Is the tapering revealing an iatrogenically caused problem in the body or is it causing it?

Healy: Actually we should come back to neurologists because you asked me about that, should we go to them? When I was training in medicine, I had a big medical textbook and I used to like it because the paper was nice and some of the images they had were great. They had a diagram or two that caught my eye back then. It was showing the peripheral nervous system and the sensory fibers and explaining that there was a problem that then was called causalgia and that meant, essentially, burning feet. They explained that women got this a lot, more than men. It was also linked to alcohol and this was at a stage when, at least as far as I was concerned, women drank less than men. So the idea that they were getting causalgia more was maybe what just caught my eye.

So this burning feet problem was a peripheral neuropathy but no one really understood what was going on. It turns out that not only alcohol and smoking and cancer chemotherapy drugs but prescription drugs can probably cause it too, but there is a great silence about anything else, the ‘good’ drugs causing it.

That’s what I think we’ve got with a lot of the antipsychotics, the antidepressants, the anticonvulsants, the benzodiazepines and things like pregabalin, they are openly marketed for controlling the pain of burning feet. Now, burning feet isn’t just caused by drugs, chemicals cause it.

The extraordinary thing about neurologists though is they are very good on the big nerves that cause a body to move around the place, but when it comes to these little fibers and the sensory things, the things where the neurologist might ask you, “Is this painful here now,” and you say yes, it is, awfully painful and you come back a few minutes later and you say no, it’s not as painful now as it was just a few minutes ago. This is the thing they are often not comfortable with, which is this subjectiveness of it, which is the sensory symptoms can change a lot.

It’s as though you’ve got a fluctuating grid and things aren’t identically the same at every stop in the grid every time you test it. It would be great to seduce them into it and if we can show that terribly common drugs like antidepressants can cause this kind of problem and that there is a way to regrow the nerve fibers, that’s the kind of thing that might really get them interested and happy to help. At the moment, if you go to a neurologist they are not going to be interested.

There does seem to be good evidence that at least some people are affected. It’s certainly not all people who go on antidepressants. It’s probably not even all the people who come off antidepressants that look like they might have a sensory neuropathy. The skin biopsies we do may not show a positive result in all those cases and the antibody tests which have also come on stream lately. This idea that when you get your auto-antibodies tested that you’ve got antibodies to the receptors that probably are the others that control whether your nerve fibers are going to regrow are not.

So, it’s going to take a lot of trial and error. People are going along and getting the tests who really have a genuine condition, but the tests seem to say no, you don’t. What we need to think about are other antibodies. Can we test or should we just stick with taking a skin biopsy down around the ankle, or should we be trying it elsewhere as well?

Moore: This all strikes me as hugely important and a valuable different direction to look for answers. It moves the conversation on from this just being a problem of the brain to a possible problem in the wider body.

Healy: It’s really interesting. We’ve sent questionnaires out to people with the PSSD, asking them what the range of symptoms they have are. People who’ve got PSSD say to us, “Look, you’ve got this all wrong. You’re focusing too much on the genitals only,” and they are right. We only focus on that though because if we can solve this problem about how that bit of skin gets numb, we’ll have the answer to lots of things, but when they report back, we give them the option to report loads of different symptoms and this emotional numbing and things like that, but equally, there is a lot of skin things like itch and allergies and things like that, which what people need to remember is most of the SSRIs come from antihistamines. So it’s not just the serotonin system that’s actually been affected.

If you think of histamine, you don’t think of the brain. You think of skin and guts, which is where a lot of the problems happen when you actually try to withdraw from these drugs.

Moore: Aren’t some antipsychotics antihistamines too? Isn’t that where they originated?

Healy: That is where they all come from. It would be nice to solve the problem with antidepressants, first of all, because they can cause awful problems but it just seems like the antipsychotics can be harder to get off, they are just more heavy-duty.

Moore: Thank you, David. Can we touch on tapering medication burdens?

Healy: Sure and I’ve got an interesting story or two to tell you about that. I’m involved with a group who have created TaperMD and it’s really the other people in Rxisk. There is Dee Mangin, Peter Wood, James Wood and one or two others who’ve been working on this day-in, day-out for a better part of five years at least and it fits in with something that people talk about called de-prescribing, which all sounds good.

Now, the thing is there is a lot of talk about it but in practice, we’re not actually deprescribing. People are ending up on more and more drugs. We are in a polypharmacy world, where a few years ago you were on one or two drugs. Now you are on four or five and it looks like the kids coming through are on four or five to begin with. By the time they get to be as old as me, goodness only knows how many they will be on.

One prescription that you need to save a life, that’s fine. Everybody thinks that’s maybe a reasonable trade-off, but if you’re on a bunch of them and most of them aren’t life-saving, you’re going to die earlier. Actually, the data coming out points that way, but it’s not enough to just be in favor of deprescribing. I’ll explain why in a moment but it’s a system problem.

This is typical of mental health as well, I see young people in clinics these days often who are on eight psychotropic drugs. It’s a delusional belief system. The psychiatrists buy an idea which comes from the pharmaceutical companies, which is if you have a bad reaction to an antidepressant, this means you are bipolar. They might say we shouldn’t have put you on the antidepressant to begin with, or else they’ll say, we’ll add an anticonvulsant to the antidepressant. Once they add the anticonvulsant in, if you’re not quite right, an antipsychotic is also good for bipolar disorder, we’ll add that in. You might say that I don’t have quite as good a focus as I had before, they say you’ve got ADHD, take this rating scale and it shows that you’re not quite as focused as you want to be and they say let’s give you a stimulant, which is pulling the opposite way to the antipsychotic.

They are building up a bunch of drugs rather than figuring that the antidepressant we gave you in the first instance is not right. Doctors have a terrible bias towards thinking anything that’s going wrong is linked to the condition, whether it’s blood pressure, mental problems, it’s linked to the condition.

If you get worse, if things go wrong, it means you have a worse condition, which means we need to give you more drugs and you can see this. The extraordinary thing for me is when people began talking about this first around 2004-2005, they were trying to sell drugs for bipolar disorder but also they sold the opportunity, when the SSRI and suicide thing came up, to say, “You should be taking anticonvulsants,” but if you said to them, if I give SSRIs to healthy volunteers, totally healthy, normal people, they can become suicidal, don’t you think it’s the drug causing this? They say, “No, these people must have had a latent bipolar disorder.” They are saying normal people aren’t real, we just didn’t know it until we gave this drug.

Let me give you a feel of where this can go. When I came over here to Canada first, I was working in a place called Guelph. I was doing a clinic there and I was part of a family mental health team who were taking up referrals that came from 70 family doctors in the area.

The patients they referred were very good referrals, they were people who’d been on antidepressants and maybe they weren’t working all that well after about 10 years. The doctor may have tried to add one or two other things in and the things went bad. So the question to me then was what do we do now? Are they people who they figured they might have ADHD and the referral was maybe because the doctor felt they weren’t absolutely sure and they wanted some expert input, me to say yes they do have ADHD, or whatever.

Anyway, things were going well and it was in the middle of the pandemic and for me, being in the clinic was great, to be with the real Canadians, because you weren’t meeting them anywhere else. I was doing a few things that were a little unorthodox that I’d been doing in the UK for a long time, which was when you write a letter on the person to the doctor who has referred them I was copying the person in. I checked with them and said look, this is what’s going to go into your record, do you want to read it and if there are things wrong, you can point that out the next time we meet. The other thing was when I emailed things to people, they had my email and if they had problems they could get in touch with me over the weekend. Some people were trying to withdraw from drugs and things like that.

I wasn’t trying to get everyone off their drugs. When people were on eight or nine drugs, I was trying to get it down by one or two drugs, all things being equal, slowly, without trying to push it. I was also saying things like we need to recognize you’ve been on this SSRI for 10 years. Some of the problems you’re talking about are that you are withdrawing from the drug even though you’re on it and there is no easy answer for this. No one has an answer, there is no drug approved for that.

The potential problem is, if you write a note like that to the patient and doctor, the doctor may feel they made a mistake. They are being accused of putting the person on the SSRI when they shouldn’t have done so. Almost always I have said, with this person’s problem, if I had seen them 10 years ago, I would have done exactly the same thing. We all have a problem. You, me and the patient, we all have a problem we need to work on.

One day, at the end of the year, I had an early morning Zoom meeting with the management and they said to me, “You are fired.” I was asking why and I didn’t believe what they told me to begin with. I thought it has to be all sorts of other things. There were all sorts of other things that sounded like reasonable hypotheses about what was going on, but in essence, what they said to me was, “What you’re doing is great if you’re doing it in private practice. If you had a shingle up in the door telling people that you’re open to getting them off the drugs they are on, not getting rid of them all but just paring it down and that you’re maybe open to the fact that drugs may be causing half of the problem they’ve got and people chose to come along that’d be great, but we run a public service and we don’t have the staff to stream patients, the ones who want to get off drugs to you and the ones who want more drugs to the other doctors.”

Essentially, the system was geared toward the sense that some people and some doctors want people to get more diagnoses and more drugs. So that’s what happens for all people. Most of the feedback that I was getting from the doctors or the patients I saw was this is great. We’ve talked for an hour and you haven’t told me I need drugs. This is a big surprise, but it turns out there were two or three doctors, probably four or five patients and I haven’t been told the figure, but everyone else, all of the other doctors and all of the other patients are trapped. They are in a system where they are going to be given more diagnoses and more pills whether they like it or not.

So, while there is a bunch of us talking about deprescribing and reducing medication burdens and TaperMD is the thing we’ve created to try to help with that, that’s not the way the tide is going. The tide is not going out, it’s still coming in, where most people are going to get more labels and more pills and there are some people who will be unhappy if they don’t get more diagnoses and more pills.

Moore: David, I am so sorry you had that experience.

Healy: It tells people how things are going. It’s not unique to me, I’m sure, but it really does point to the kind of situation we are in to which there is no easy answer.

Moore: This issue of polypharmacy, David, what is driving it? Do you think it’s because doctors generally believe that the drugs are benign and they can prescribe whatever they want with no problem? Or do you believe it’s because there is an unwillingness perhaps to question the medication burden already established?

Healy: It’s very hard to know and we’ve got the Green Party and Greta Thunberg talking about the pollution of the environment but equally, even the Green parties and young people of Greta’s generation seem to almost want to pollute their inner environment, more than ever before, which is an extraordinary contrast.

So, it comes back to this certain amount of insanity in the mental health system. One of the myths that turned up 20-odd years ago was that antipsychotics are neuro-protective. We can see with our own eyes that we’ve got people ending up with tardive dyskinesia and problems like this who have severe neurological problems. How on earth anyone can think that these drugs were neuro-protective, I don’t know, but they do. They actually think it intensely and if you ask them for the evidence they can’t actually provide it. This is delusional.

It’s hard to know how to solve it. We are working hard on this TaperMD approach, which seems to make sense. It’s recognizing that doctors don’t want to recognize the harms they do. That they just want to think that they are doing good.

Moore: Which you can sympathize with. If there are only so many levers that you can pull, you’re going to pull the easiest one, aren’t you?

Healy: Sure, but what we’re trying to do is to say look, if you’re going to do good, as much good as you can, you’re not doing more and more good every time you add a pill in. It looks like and all the evidence points to the fact that once you go much above three pills, you’re beginning—even if you’re putting the person on the drug for a condition that they have and the pill might have, once you get beyond three, you’re likely doing harm and you’re going to cause them to die earlier. When you’re trying to reduce medication burdens again, the evidence is that they are less likely to go into hospital and less likely to die earlier and actually just feel better.

So, there is a real issue and it’s trying to appeal to the sense of judgment of you are the doctor and you are the patient, as well, because they are actually part of the problem too. We are part of the problem too. It’s not a crime to want to help with things but what we need to recognize is we’ve got to make choices. Once you’re on too many helps, they are going to kill you. So, the trick is to sell the idea that to do the best amount of good, we need to control how many drugs you are on.

Moore: In terms of the increasing creep of the number of people on medications there has been a big focus on the elderly. I’ve seen articles from Canada reporting that in old people’s homes, 75% of the residents are on antipsychotics, not because they’ve ever had a psychotic experience but because it keeps them quiet and sedated, which is just dreadful to read.
Recently here in the UK, it’s been reported that children are being prescribed antidepressants in GP surgeries at very young ages. I could be wrong but I think there is only OCD that’s indicated for antidepressant treatment in youth. I wondered if Canada was similar and what you felt about it.

Healy: Yes, it is. You’ve got teenagers who are keen to go on these drugs and it can be a tricky problem. I can think of one person I saw, a terribly nice young man with a very nice mother who had tricky things to deal with that made him anxious an antidepressant would help. I told him about the risk of problems and he said, “Sure. No, I can see that. I can see that that’s a good case for not having them,” and things like that and he didn’t come back to see me.

He was there in the clinic with his mother and she was also a very reasonable, very nice woman. He didn’t come back to see me and he went elsewhere to get an antidepressant. My hunch was, one of the things linked to it was his mother was on one as well. So, it’s one of these cumulative things where if you’ve got parents who are on antidepressants who say, “Look, I am on them and they are okay. They are not causing all the awful things that that guy said they could cause,” you’re going to have a situation where if the child doesn’t go on them, it’s making the mother look bad, why is she on them kind of thing.

Talking about Peter Groot, there is also Peter Gøtzsche whom people listening to this will have heard of. Just last week, Peter had an article out which is reanalyzing the Prozac trials in kids. We all hear the whole time that Prozac is the one SSRI that works well in youth. It doesn’t. The FDA internally concluded when they approved it that it didn’t work in the trials that they were looking at, but they agreed to approve it anyway. It remained approved despite the fuss that blew up about paroxetine after the Panorama program (“The Secrets of Seroxat”), so they couldn’t approve that but everybody said, “At least you can use Prozac because that’s approved for kids who are depressed.” Exactly the same kind of results, it should not have been approved, but once they had approved it they weren’t going to go back.

It’s not that SSRIs are totally useless for kids, as you said, in OCD they can help but we have a system as well which feeds into this. One more point and it’s a political point, which is that systems can make good people bad.

I think what you see in all of health, but mental health in particular is you see some people who become part of the management system who end up doing terribly vindictive and inhumane things to people who don’t respond the way they should do. Rather than going back and saying we need to take more care with you, we need to look at this, not do the things we used to do because they are clearly making things worse. It’s at this point the delusional belief that everything that goes wrong is your condition. So if you’re not getting better, we’re just going to give you more of the same.

So, they are doing that as part of the system but also because above them is a group of managers who we didn’t have 20-30 years ago. Their job is to squeeze the system, so it’s using less money and saying to the bosses and the politicians who are above them, we’re getting better and better ourselves for less and less money. That’s putting pressure the whole way down to the system, which the person who comes along for help ultimately feels that the doctor or the nurse treating them is not in a position to deal with them as a human being. They are in a position, which is, if I don’t get you to tick the right boxes, my job is at risk. It’s a very toxic environment.

Moore: That tick-box culture is causing an awful lot of harm, isn’t it, because it’s not based on outcomes for the patients, it’s based upon things you can actively and easily measure as a throughput. We’ve dispensed X number of drugs or we’ve administered X number of procedures for people, rather than asking people how they feel.

Healy: Yes, and the system will work a lot better if we let people drive it, rather than trying to drive them.

Moore: It makes me think about when I had my interaction with my psychiatrist who prescribed to me and if I could go back and change that. What I would have liked her to say to me is, “James, if we prescribe you these drugs, they will make you feel different. That different might feel better or it might feel worse. So, come back in six weeks and we’ll talk about whether that is a better feeling or a worse feeling for you,” but there was no discussion whatsoever. It was just a “you will improve on these drugs, no question” and when I did go back and say I wasn’t, all of a sudden I wasn’t believed, as you mentioned earlier.
If we could have more honest discussions with people that the drugs do make you feel different, they can have an effect, but that effect might put you in a better place or it might put you in a worse place. I can’t help thinking that that would be more healthy.

Healy: Sure, but also to add into that, the key extra thing is you need to know that you are the expert on what’s happening to you.

We’re in a strange world, where if someone says, “Look, I’ve taken up smoking recently and it’s really helpful,” 99.5% of doctors would say, “I’m not going to treat you anymore if you keep on smoking,” but in fact, this is the world we are in, which is you can treat nervous problems with alcohol and smoking if you are a good doctor and patients are treating themselves often very successfully.

We need to take into account that there isn’t the good book and the bad book, or the good drug and the bad drug. These things are all tricky and to get a good outcome needs cooperation. Both the person who is going to take them and the person who says, “Look, what about this option?” You all need to be cooperating and open to change. I’ve learned something out of this, something that I didn’t expect has happened.

Moore: It’s rather like the dietary advice that we’ve been given for probably two decades now to avoid fat in our diets, but no mention at all of sugar and that’s primarily because there is an industry lobby body for sugar but not one for fat.

Healy: It’s exactly the same. We have been herded along by lobby groups and that’s what’s happening to us. We are in a herd, we are being herded along particular paths and when it’s inconvenient, but when the lobby groups aren’t making money out of that path, they will switch us over to maybe the psychedelics, or whatever.

Moore: David, it’s always a pleasure and an education to get to talk about these things with you. I have to say that the articles on Rxisk about PSSD and neuropathy are fascinating and I do recommend people go and read them, not just for the blogs but for the response from commenters too. It’s the idea of picking up the rugby ball and running with it, which is fantastic to see.
Before we wrap up, I do just want to acknowledge that I am so grateful to you because you are one of the few doctors who will get down in the weeds with people like me who have experienced difficulties and have an eye-level conversation with people about their experiences and what they might have learned.
There is so much humility in doing that that’s missing from many doctors that I’ve interacted with who just put themselves on a pedestal. Also, your long history of curiosity and of looking at these things through a fresh lens and a different perspective.

 

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