(Dr. Shipko's 6th visit to Power Surge)


Mary:   Before I introduce our guest tonight, Power Surge Founder and Host,
Dearest, asked me to express her regrets at having to miss only her third 
guest chat in eight years.  She asked if I would sit in in her place, so I'll be 
your host tonight. 

It is my pleasure to welcome back to Power Surge,  DR. STUART SHIPKO, Director 
of The Panic Disorder Institute. Dr. Shipko is a Psychiatrist and Neurologist 
whose practice focuses on panic disorder, stress-related medical conditions, 
stress and trauma related disorders, psychiatric injury, psychosomatic medicine 
and general psychiatry. 

Welcome back, Dr. Shipko. Let me begin by asking you Dr. S., if could you kindly 
explain exactly what SSRI's are and how serotonin works naturally in our bodies 
without SSRI's?  


Dr. Stuart Shipko:   We should mention that the topic for tonight is SSRI 
withdrawal and side effects.  SSRI's, Paxil, Prozac, Zoloft, Celexa and Luvox 
(and sort of Effexor) are the SSRIs.

They increase serotonin at the level of the synapse, But no mechanism of action 
has been fully determined for them.  Serotonin does a lot of things, but tonight 
I want to focus on the drugs.  

Withdrawal. SSRI withdrawal is emerging as a very significant problem.  The 
exact incidence of people having withdrawal when trying to stop a SSRI has never 
been documented.  One study cites withdrawal symptoms in Luvox 86% of the time 
and with Paxil 50% of the time.  In my experience the phenomenon of dependency 
and withdrawal is relatively common.  

Although SSRI withdrawal has been well documented in the literature it is almost 
never taken into consideration in the prescribing practices of these drugs 
(Paxil, Zoloft, Celexa, Prozac, Luvox).  Despite the fact that about 1/3 of 
family physicians and 2/3 of psychiatrists state that they are aware of 
withdrawal, patients are hardly ever warned of this when they are prescribed and 
when it occurs it is rarely identified.  It is as if theyre meaning doctors. 

Drug dependence has two major components:  tolerance and withdrawal.  It is well 
known that tolerance to the SSRIs is common, or "poop out" over time.  As they 
become ineffective the dose is usually increased to maintain some effect.  
Literature cites that SSRI's poop out about 1/3 of the time.  Most physicians 
will increase the dosage as effect is lost and few physicians will consider the 
possibility that tolerance is occurring and decide to discontinue the drug. Many 
people are no longer getting any effect from their SSRI even at the highest 
dosages.   Frequently they continue to take it because when they try to stop it 
they develop withdrawal symptoms. 

When stopping a SSRI, the higher the dose and the longer the duration of use, 
and the shorter the half-life of the drug, the more severe the withdrawal 
reaction is going to be.  Despite descriptions of withdrawal syndromes 
GlaxoSmithKline, manufacturer of Paxil, which has a short half-life and the 
pronounced withdrawal, provides doctors with a brochure that says "no 
association has been made between Paxil and addiction."  This is misleading.  

It would almost seem as if the manufacturer is going out of their way to be 
deceptive about the addiction issue.  A lawsuit is in progress that contends 
that GlaxoSmithKline knew about withdrawal and deliberately hid it from the 
public.

I wanted to get some foundation for the discussion.  Well, I could go on, but I 
will take questions now.


Mary:   Thanks, Dr Shipko :) 


Scarlett:   Just wondering if there were ever a good reason to use these SSRIs?


Dr. Stuart Shipko:   Yes, they have their place in psychiatry, but they are 
being overprescribed and inappropriately prescribed.


Wildflowers:   I was given Paxil a few months ago in a plastic bag from my 
doctor - 10 mgs. per day for a week. Then to up to 20 mgs. Stayed on 10 mgs. 
for 13 days. Tried one 20 mg. and was very sick. Was sick for the whole time 
on Paxil. Quit cold turkey. It took one week to feel somewhat normal. I was 
then given a benzodiazapine a few weeks later to take as needed. It works for 
me.  I feel fortunate to have gotten off Paxil as soon as I did -- very scary 
on and off. 


Dr. Stuart Shipko:   All too common.  The most frequent form of prescription is 
to give a bag of samples to a patient with little instructions and no warning on 
side effects.  Glad you are off Paxil. 


Theresa343:   I have been on Zoloft for about 10 years. I have tried to come off 
3 times and 3 times the depression comes back.  It is worse. I have even 
considered suicide. How does one come down from an SSRI? I had a surgical 
menopause 12 years ago. and started Zoloft at 25 mg and now take 100 mg a 
day. I also take 1 mg of Ativan PRN. Please help.


Dr. Stuart Shipko:   Some patients are going into withdrawal while still taking 
the drug if its effect has worn off and the dosage is not increased.  Physicians 
tend to either add in a second drug or to try to change to yet another SSRI.  
One reason why SSRI drugs are continued is that when they are stopped the 
patient becomes quite sick, emotionally and physically, and no real "antidote" 
is available except to restart the SSRI.

Zoloft, in particular seems to have severe, tearful depression as a major 
withdrawal effect.  There is no antidote and I am working on this now -- 
thinking that perhaps boosting nutrition will help.  Tapering slowly is not 
always enough.  It can take 3 or 4 months for the severe depression to pass.  


Noah:   I had the same experience as Wildflower but with Zoloft 12.5 - 3 weeks, 
was 'high', shaking, drove weird, felt like detox then serzone, severe allergic 
reaction. Now on Remeron 8 months. Today given EFFEXOR. I am chicken to take it.


Dr. Stuart Shipko:   Shouldn't you be afraid to take it?


Noah:   : ) yep


Dr. Stuart Shipko:   There is your answer, Noah.


Gypsynmo:   I have been on Zoloft for about 3 months, don't see where it's doing 
me any good. Will I go through withdrawal if I stop it now?  I have Lupus also.


Dr. Stuart Shipko:   Gypsy:  The shorter the duration and the lower the dose, 
the less likely you will be to have withdrawal.  Not everyone does.


Shauna:   What type of withdrawal symptoms are common on drugs like Paxil?  I am 
on Prozac once a  week pill for treatment of depression and anxiety related to 
Cushing's Syndrome.  Is withdrawal different when on the once a week 
prescription? Thanks.


Dr. Stuart Shipko:   Shouldn't Cushing's Syndrome be treated with adrenal tumor 
removal?

Well, anyway, The withdrawal symptoms from the various SSRIs are similar and 
discreet SSRI withdrawal syndromes have not really been described.  The major 
categories of withdrawal are: 
     1) vertigo, tinnitus and dizziness 
     2) electric shock like sensations of the head, neck, and shoulders (zaps) 
     3) nausea and vomiting 
     4) flu like symptoms 
     5) nightmares and insomnia 
     6) irritability 
     7) new onset of a severe depressive syndrome characterized by v and 
     8) new onset of intense somatic anxiety lasting minutes to hours not           
     present prior to taking the SSRI.



Bynum:   Do SSRI's effect the balance mechanism of the inner ear/brain?


Dr. Stuart Shipko:   Bynum:  Yes they do.  They cause tinnitus and dizziness 
when you start, and more tinnitus and vertigo as part of withdrawal. 


SheWhoHowls:   What about for those of us who are doing it in the raw - no drugs?  
I tried for 4 years and finally took Premarin this June. I still have anxiety, 
irritability, grief, low level depression, if I allow it. Am ultra sensitive.  
What can those like me do?


Dr. Stuart Shipko:   Whatever you do, be informed.  The SSRIs do work for some 
of these problems, but at what risks?  


Aunt:   Dr Shipko.  I hate drugs.  Any kind of drugs.  I am afraid of them.  
With all of the horrible symptoms that we menopause women go through, and all of 
the side effects that these drugs have, why oh why would any Dr. prescribe them?


Dr. Stuart Shipko:   Right now we are in a unique period where the drug 
companies have domination of academia, journals, education.  Doctors are often 
misinformed. 


Aunt:   Dr. S, that is scary. 


Dr. Stuart Shipko:   You bet, Aunt.  


Aunt:   Thank you Dr. S


Caregiver:   My mother has had anal cancer, chemo and radiation, anxiety and 
depression this year.  Has had a lot of gastro complaints including nausea and 
diarrhea.  They tried her on a few SSRI's which activated her and seemed to 
cause more diarrhea.  Any suggestions for less activating medication and less 
chance for gastro problems?


Dr. Stuart Shipko:   Caregiver, this is a complex question and well beyond the 
scope of an Internet chat.  Sorry.  


Mary:   Please remember that the information you're receiving here is not 
intended as a substitute for a visit to your own doctor.


Wildflowers:   Years ago by same doctor I was given Zoloft because my symptom 
was not being able to sleep. I took ONE pill, don't remember the dose, I actually 
sat with my back against a wall for several hours and felt like I couldn't 
move. The serotonin drugs are just too powerful for me. I, too, feel better 
knowing I'm controlling what I take as needed as opposed to a drug that stays in 
me at varying levels. I feel when I don't need the benzodiazapine I don't take it 
to keep the level.


Dr. Stuart Shipko:   Is there a question? 


Wildflowers:   Sorry, just a statement I guess.  Thanks


Dr. Stuart Shipko:   Thank you.  


Gypsynmo:   Would the Zoloft cause problems for someone with lupus?  or could be 
caused from Premarin?


Dr. Stuart Shipko:   You can get side effects or beneficial effects any time it 
is used.  No special problems in association with Lupus or Premarin.


Gypsynmo:   I went off the Premarin and see no difference in my Lupus, except so 
severally depressed.


Bynum:   Can the dizziness continue forever? As in "no cure"?


Dr. Stuart Shipko:   It can persist a long time (months or a year) but it 
usually goes away after a few weeks. 


Mary:   Thanks, Dr S!   Sisoy, go ahead with your question, please.


Sisoy:   Dizziness, sometimes worse than other times. I feel like a drunk, 
without the alcohol.


Dr. Stuart Shipko:   Sisoy:  as a side effect or withdrawal effect?


Sisoy:   None, just happens.  No drugs except natural progesterone creme.


Dr. Stuart Shipko:   I see, as a problem aside from SSRIs.


Pinky:   I have been taking Trazodone for over a year for depression with 
anxiety.  Before I took it I could not sleep. I also take birth control with no 
weeks off so I won't get a period, per my doctor. What are your thoughts on 
Trazodone? I could not tolerate SSRI's.


Dr. Stuart Shipko:   Trazodone is a good sleeping pill and has been used 
primarily as a sleeping pill for over a decade. 


Pinky:   Yes, but it is effective for depression? 


Dr. Stuart Shipko:   Pinky:  it is weak for depression.


John:   What about the MAO inhibitors over the SSRI's?


Dr. Stuart Shipko:   MAO inhibitors are very good for anxiety and depression.  
They have hypertension as a major side effect and diet must be regulated.  But 
they work well over long periods of time.  


Aunt:   Ok you know how I feel about drugs.  My question is this, how do we 
menopause women deal with the horrible effects of menopause in a natural way.  
What are your suggestions?


Dr. Stuart Shipko:   The most natural way, is no drugs.  I hear good things 
about cohosh, some people do need HRT.  Dearest speaks often of soy. 


Aunt:   Thanks


SheWhoHowls:   We have talked about what not to do...what can we do (education 
is still communal not personal)?  There is help, it seems, for those who chose 
the SSRIs, is there help for those of us who do not? (same as Aunt's question 
but there has to be alternatives to any drugs or non-drugs.  I am allergic to 
soy.


Dr. Stuart Shipko:   SheWhoHowls, what to do is a whole other issue.  The 
chat tonight is focused on the problem of SSRIs which are being prescribed for 
this in bulk.  


Bynum:   What do you think of Klonopin for dizziness? I am fearful because of 
its use as a seizure drug.  Any side effects?


Dr. Stuart Shipko:   Klonopin works for dizziness.  The major drawback is 
dependency, memory problems and sedation.  That it was developed as an 
anticonvulsant is not really important.  It is a lot safer, IMHO, than a SSRI.  


LibraDoll:   At age 50 had a total hysterectomy and have symptoms of menopause 
and anxiety/depression, what do you recommend. 


Dr. Stuart Shipko:   Can you get by without drugs? 


LibraDoll:   I'm having a hard time. 


Dr. Stuart Shipko:   LibraDoll:  What do you think about HRT? 


LibraDoll:   If I could find the right one it'd be great, just having a hard 
time.  Is there one that you'd recommend?


Dr. Stuart Shipko:   I really don't specialize in menopause.  It is complex.  
Hormones, diet, exercise, anxiolytics -- I would avoid SSRIs though.


LibraDoll:   Do you need HRT and antidepressants to get through this?


Dr. Stuart Shipko:   It is different with different people and beyond what a 
chat can offer you. 


Ravin:   Thank you. Dr., Can stress cause more severe dizziness than is normal 
with Anxiety that lasts overnight?


Dr. Stuart Shipko:   Ravin:  I don't understand your question.  


Ravin:   May I clear it up?


Dr. Stuart Shipko:   yes


Ravin:   I have chronic dizziness with anxiety/Panic and 4 weeks ago I had a 
weird attack that lasted even through 6 hrs sleep.  It was still there when I 
awoke.  The eyes not focusing and dizziness, I mean.


Dr. Stuart Shipko:   Once again, these are complex symptoms that should be 
discussed with your doctor. 


Christine:   I decreased my Paxil dose by only 5mg over a month ago. is it 
possible to still feel symptoms of discontinuation?  and could these include: 
significant dizziness, headaches, mental confusion, nausea, anxiety?


Dr. Stuart Shipko:   Yes, commonly.  


Christine:   How long can these symptoms last?


Dr. Stuart Shipko:   Several months.


Christine:   I am having a great deal of difficulty getting off Paxil :(


Dr. Stuart Shipko:   It is very much like the SSRIs.  It has a pretty intense 
withdrawal.  Weight gain.  Sexual problems.  


Mary:   What is PTSD, please? 


Dr. Stuart Shipko:   Post Traumatic Stress Disorder


Athena:   I am worried about SSRI's and anxiolytics (benzodiazapine in general) 
after reading that after long-term use (over 12 months) there are possible side 
effects such as memory loss, loss of concentration etc. I have voluntarily 
withdrawn from Lorezapam for that same reason.


Dr. Stuart Shipko:   And do you have a question? 


Athena:   Yes, sorry, about the side effects mentioned.


Dr. Stuart Shipko:   These can be significant side effects and it is good to be 
cautious. 


Athena:   OK, thank you 


Mary:   Could you please tell us a little about what SSRIs are? 


Dr. Stuart Shipko:   Mary:  the Selective Seratonin Reuptake Inhibitors - Paxil, 
Prozac, Luvox, Celexa, Zoloft. 


John:   If Xanax and Klonapin don't work for PNE, would you use an MAO inhibitor 
before an SSRI? 


Dr. Stuart Shipko:   In general, yes.  


Arthur:   How do SSRIs affect people's sex life?


Dr. Stuart Shipko:   Good question.  On Paxil and Zoloft, about 80% of people 
have some sexual dysfunction.  Usually inorgasmia, but also problems with 
arousal.  I have reported three cases to the FDA of sexual dysfunction that did 
not clear up with stopping the medication.  


Taz200:   What about tricyclics?  Withdrawal, dependence, etc.?  Side effects?  
Sexual dysfunction?  TCA vs. SSRI?


Dr. Stuart Shipko:   Taz:  too broad a question. 
TCAs are kinder regarding withdrawal and dependence, although these are still 
problems. Overdose on a TCA will probably kill you, and this is less common with 
the SSRIs. 


Suzi:   I've been on 50 mg Elavil and 15 mg valium for 6 years.  How long can 
one stay on this regime?


Dr. Stuart Shipko:   You can stay on it indefinitely.  


John:   Do MAOI's have sexual side effects?


Dr. Stuart Shipko:   Yes.  Less so than SSRIs,  but this can be a problem.  


Mary:   Dr. Shipko, thank you for a fascinating and informative chat and for
fielding our questions about SSRIs, panic disorder, anxiety, depression, et. al. 
Dr. Shipko invites everyone to visit his Web site at http://www.algy.com/pdi.



Dr. Stuart Shipko: Thank you for having me. 


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