Dr Louise Newson: [01:00:00] Mark Horowitz is on my podcast today and this is actually going to blow your mind. You might have to listen to it more than once. We talk about antidepressants, we talk about benzodiazepines, we talk abut gabapentin, pregabalin, these highly addictive drugs that are prescribed more commonly than HRT and have more risks with them. We need to be thinking differently about mental health and his perspective on things including his research is really interesting and I just hope it makes you think a bit differently. So, Mark, this is great that you've come in today. I know it's going to be a very interesting podcast that's going resonate with a lot of people. People might be wondering why I'm holding such a big, heavy book that I've slugged across London, but it's The Maudsley Deprescribing Guidelines: Antidepressants, Benzodiazepines, Gabapentinoids, which is gabapentin and pregabalin, and Z-drugs, which are the sort of Zopiclone sleeping tablets. And you are a co-author of this. And You've written so many papers, your knowledge is huge, and I just wanted to get as much out of your lovely brain for the next half an hour. So just before we start though, just explain a bit about your background, if you don't mind.

Dr Mark Horowitz: [01:01:16] Thanks for having me on, and if the book is heavy to carry, imagine how hard it was to write. So thank you. So I'm Mark Horowitz, I'm a trainning psychiatrist and researcher. I'm an associate professor of psychiatry at Adelaide University, and I'm a visiting lecturer in psychopharmacology at King's College London, and I run a deprescribing clinic that specialises in helping people to stop antidepressants, benzodiazepines, all the drugs you mentioned, in the NHS in Northeast London. And I also work with Outro Health in America that does similar things to help people come off antidepresants safely. And I've done a lot of work exactly dealing with half of psychiatry, I think, which is how to safely stop medications, because so much of psychiatry is about how to start them. And I, you know, sometimes I think it's a little bit like having cars without brakes on the, on the road that I'm looking at how to safely stop these things.

Dr Louise Newson: [01:02:09] It's really interesting actually so I was reflecting a lot coming here today because I qualified in 1994. Antidepressants, the SSRIs, were just sort of coming out really. Before that we had antidepressants like amitriptyline, dithiopine, but they had more side effects so we were a bit more careful and they were quite immediate side effects people had, you know, the dry mouth, sometimes blurred vision. So when they came out I remember because when I did my training in general practice, there were more drugs than when I do my psychiatry training, if that makes sense. The adverts were very, oh, it's very easy, it's very safe, it is very low, and low risk, just prescribe them. And you know, as a doctor, we don't really get trained much about lifestyle medicine at all. So when you've got someone in front of you for 10 minutes, it can be really difficult tease out firstly whether they are clinically depressed. Or whether they're reacting to a dreadful situation, or whether there's something else going on. But also like, how do you take responsibility? How do you manage them? It's, there's a lot, quite a lot of pressure as a GP. So I do feel bad for lots of reasons, but I've prescribed a lot of these drugs. I prescribed a lot of sleeping tablets to a lot women thinking back who really couldn't sleep. And I was just on this sort of hamster wheel, like a lot of people are, because I thought what I was doing was right. And I think it was at the time. But there's a couple of things, really. One thing is, obviously now I know about the role of hormones in the brain, and when I think back to the women who I've prescribed to, I didn't ask about their periods, I didn't ask if they had any change throughout their cycle, I didn't ask about postnatal depression, which is often a sort of sign that they might have worsening mental health when their hormones changes their age. And now, obviously I prescribe hormones, but I deprescribe a lot of these drugs. I'm constantly thinking, how can these people come off those drugs? Because there are harms with them. There are long-term risks. And I'm thinking so much more about how to not prescribe them in the first place. In the last six, eight years, probably, I haven't prescribed any of those drugs. And I would say my patients that I look after now are healthier than the patients I've had before.

Dr Mark Horowitz: [01:04:35] I mean, I guess there's a lot to dig into there. I mean number one, I think it does impose on GPs a very big pressure that I think is, people have all sorts of problems, physical health problems, social, psychological problems, and GPs are there with eight to 10 minutes to try to solve them. I think there's lot of pressure on them to deal with that. We know that most people's low mood is because of their life circumstances. Study after study shows the number of stressful life events you experience in a year correlates very strongly with whether you're depressed or not. The sort of things that before the kind of biomedical era, people would have said causes depression, job loss, divorce, death of a loved one, those are the big risk factors. We have hugely medicalised these conditions over the last few years where everything is now has capital letters, it's Major Depressive Disorder, Generalised Anxiety Disorder. But these things are responses to our lives. Lots of people get better naturally. We know that after the process of natural recovery is very efficient. Most people who are depressed six months later will not be depressed because things change in people's lives. We have this sort of intervene quickly mentality. So GPs want to do something useful, they want to be helpful. That's part of their training. They want to get in there and do something. But we know that people that are not prescribed antidepressants have the same sort of outcomes as people that are prescribed antidespressants. So there's not huge evidence for their effectiveness. Especially in the long term. So a lot of studies on these drugs are done for a few weeks. There's very small differences. You need a sort of magnifying glass to see it on these studies and there are very few studies on long-term effects. So I think a lot of people are being prescribed these drugs too quickly, for too long, without reference to the long- term consequences, which we can talk about, including how hard it is to stop these drugs.

Dr Louise Newson: [01:06:27] Yeah, and some people really do feel worse when they take the drugs. And I know looking at some of the studies, people were saying, well, it's because these people have mental health issues anyway, so their suicidal thoughts or whatever that happen are not because of the drug, they're because of how they are, but there has been increasing evidence that there is a cohort of people whose mental health has spiralled out of control on these drugs, which is a concern, isn't it?

Dr Mark Horowitz: [01:06:52] So I find that very irritating when people blame the underlying condition because it's very clear. the FDA did a very big meta-analysis now 15 years ago. They looked at double-blind randomised control trials. That means that the people in both arms of these trials have the same mental health conditions, so you can't blame the mental health condition. That's the whole point of doing these trials. In the group of people given antidepressants, there was more suicidality than the group given placebo. That was particularly true for young people and that's why in America antidepressants come with a black box warning that under the age of 25, these drugs can increase your risk of suicidal thoughts and acts. There's been a lot of shifting around of words by the MHRA and different drug companies to make it sound like it's because of the underlying condition, but that is just not true. The double-blinded studies show that it's the antidepressants that are causing that increase in suicidality. So you're quite right. It's something to be concerned about. When you talk about older adults between the ages of 25 and 65, there is more debate. Some analyses show that antidepressants increase suicidality, some show they have no effect, but no studies show they decrease suicidality. So when people say that these drugs are life-saving, it really is a marketing line because that has not been shown in any studies. People might say that about the drugs that they take, but who might say it about anything they do in their lives, but looking at the evidence as we have to as doctors. The objective evidence doesn't show that these drugs reduce suicidality. That's not what the studies show.

Dr Louise Newson: [01:08:22] And that's really important, I think, for people to know. When they first came out, we could prescribe them to children.

Dr Mark Horowitz: [01:08:28] They're still prescribed to children.

Dr Louise Newson: [01:08:29] And they are still prescribed, but not so much as from GPs, but because mental health services are so stretched, there's more onus then on the GP. If you've got someone in front of you that's got mental health issues and you know it's a really long wait for CAMS or for a referral and you see these people, it's really hard. I was very fortunate. I had a really good trainer when I was a GP and he kept saying to me, Louise, you can't change people's home circumstances, but what you can do is change the way they think about them. And so I spent, and he did quite a lot of cognitive behavioural therapy actually. And it was quite a little bit about what you can accept and what you change and it's the mindset. And it can take a bit of time, you can't just do it all in 10 minutes, but I was very fortunate because where I worked as a GP, I really got to know my patients and their families. So you knew like sometimes it was a breakup of a relationship. And then next time they'll be with someone else and something would happen. Or it might be an abusive partner and it's working how you remove yourself from the violence or something rather than being medicalised for it.

Dr Mark Horowitz: [01:09:37] Exactly. I think, I mean, you know, this is what happens with medicalisation. You swap problems. So you're talking about all sorts of domestic abuse, relationship problems, job issues. You know, the way to solve those problems, you might need social workers, you might need to change, you know, financial services, there might need be things that have changed. If you turn it into an issue with chemicals in someone's brain, then you're thinking about which drug works and side effects and doing research on brain chemistry. I think you're missing the problem. You can't. so I think that's what you know, medicalising has done is it's confused people. I remember reading an article saying there's rates of depression that are rising in teenagers because of bullying and financial stressers. And what we want to do is do more research into the brains of these people to work out why it's happening. It's such an absurd response. If the issues are bullying and financial pressures, then of course the solutions are school dynamics and redistribution, support of people with low incomes, not looking at what goes wrong in their brains. But because we live in such a sort of technophilic age, where understanding how brains work is the answer, we've forgotten the sort of basic social factors that push these things. I think it's hard for a GP because sitting there, as your trainer said, how can you change people's lives? It's very hard, which is why I don't think it's best seen as a medical problem because GPs are very good at managing blood pressure and diabetes. But when you're talking about social problems, they may not be the most appropriate people to deal with these things, but medicalising it has put it in their laps. Which puts them in a very difficult position, which is why it's so easy to prescribe a medication, because you can do that in eight minutes.

Dr Louise Newson: [01:11:08] Yeah and the thing is also with psychiatric diagnosis there's all this DSM criterion and as doctors we like to make a diagnosis because it helps dictate treatment and also it can be, not always I think, but it can be validating for a patient to know they have a condition. You know if you were feeling really tired and lost weight and I did your blood sugar level and your glucose level was really high and I told you you had type 1 diabetes you'd be quite relieved with a diagnosis and a treatment that was effective. But some of these criteria are firstly, very rigid. Secondly, you can talk about some of the politics maybe behind them. But then as soon as you've got that, then it triggers the medical treatment, doesn't it?

Dr Mark Horowitz: [01:11:51] So I, exactly. I think the route into medicalisation of these conditions is diagnosis and as you've alluded to diagnoses, when you talk about type 2 diabetes, you talk about blood sugar levels, you're talking about insulin responses, there's biochemical findings. Talking about mental health conditions, of course, there are no biochemical findings. These things are social constructions. They were, you know, the modern age of psychiatry was unleashed in 1980 in the northeast of America by the DSM-III committee. So, you know, I think it's worth.

Dr Louise Newson: [01:12:20] Just explain that, yeah.

Dr Mark Horowitz: [01:12:22] So in the 1970s, psychiatry was under attack by psychologists who said, you know, we're better at therapy and we're cheaper. What are you guys doing? And their response was, you know we're aware of doctors. We have medical degrees. We understand the way the brain works and DSM-III was the response to that. Before that, DSM-I and DSM-II had been very psychoanalytic in orientation. They had different chapters on reactions, depressive reaction, anxious reaction, even psychotic reaction. And the reaction was to people's lives, things that go wrong, some people respond by becoming hopeless, some by becoming very anxious, very common responses. DSM-III, those categories were changed. Depressive reaction became Major Depressive Disorder, capital letters. Anxious reaction became Generalised Anxiety Dsorder capital letters. Was that because of new biochemical findings, neuroimaging, epidemiological studies? No, it wasn't. It was because they wanted to enforce that these are medical conditions like anything else. And so they sat around, there are these interviews done by James Davies where he asked the committee members, how did you come to these diagnostic criteria? And they said things like, it was a bit like a group of friends ordering, going out for dinner. And in the end we would vote on the right criteria. And they said things like six criteria was too many, four was too few. So we decided on five criteria. And also they said things like, you can't put that symptom in the diagnostic criteria because I do that. It was very much shaped by their own notions of what is normal, what is abnormal based on middle-aged white men, professors of psychiatry in the 1970s. Sort of famously, of course, in previous versions of DSM, homosexuality was a diagnosis that then became out of favour as social mores changed. So you can sort of see how socially determined these things are. And so you're right. Now you have this diagnostic set of criteria, a capital letter diagnosis. It sounds like diabetes. And now you're in the realm of the medical where of course there are guidelines that say if they have this diagnosis, give this medication. And so now you've been shunted, all these different life problems have been shuntered into a diagnostic lane. The other thing to say along with this is how common depression is. People, they say, oh, it happens to one in four or it's this. By the age of 45, 70% of us will meet criteria for clinical depression or anxiety.

Dr Louise Newson: [01:14:43] 70%.

Dr Mark Horowitz: [01:14:43] 70%. So, you know, it's the idea that there's something wrong with the brains of 70% of people is implausible. You know, i's a sort of natural response a lot of us have to overwhelming stress or not having our emotional needs met. It's the response of a normal person to circumstances. That's what a lot of these studies show. And of course, if you do medicalise that, there's a huge market to give people medications. And I think that's what's happened over the last few years. What was considered normal has now been, is now jumped on, diagnosed, and you're pushed down a treatment path. And of course, because the antidepressants are not so effective. A lot of people go through cycles of medication. They try an antidepressant, they're told this one's not for you, try another one. It can lead people down this route of being given multiple medications because the medications, especially if you're in a situation of domestic abuse, relationship conflict, and the issue is not being solved, but you're being medicated, these medications are not gonna solve those problems. They're not particularly effective. So you end up getting multiple cycles of medication, you're then sometimes called treatment resistant, which then makes you eligible for further treatments that people are given, pregabalin, quetiapine, you know, people can end up getting lithium or electroconvulsive therapy. You go down this sort of route of medical treatment to find something until it's effective.

Dr Louise Newson: [01:16:13] Yeah. And I see this a lot because we do see a lot of people with mental health issues, you know, one of the commonest symptoms of hormonal change is low mood, brain fog, anxiety, irritability, poor sleep, lots, there's a big overlap, of course, with symptoms of depression. So most people, and I was really surprised when I started my clinic several years ago, but most people I see have been either offered or given antidepressants, 68% of people come to the clinic. I thought with time things would have improved, but actually they haven't, but I'm seeing people that are on antipsychotics like you say like quetiapine, lithium, gabapentin, pregabalin for their moods, but also I have been seeing increasingly people that have had electroconvulsive therapy and ketamine infusions, which really scares me. Because no one's been thinking about other causes. You know, like you say, some of them are social causes, but some of them are hormonal changes. And then what really sort of concerns me is that if someone's on hormones, we have a long discussion about the difference between the natural and the synthetic ones, about the risks and the perceived risks. I don't know any of my patients that anyone sat down and told them any perceived risks or problems with any of those drugs, including antidepressants. Thanks so much for listening to my podcasts. Did you know that if you prefer to watch rather than just listen, my podcasts are available on YouTube every week. You'll find full episodes and additional educational content on hormones, menopause and women's health, all grounded in science and real clinical experience. It's another way for me to share evidence-based information, challenge outdated thinking, and make complex topics clearer and more accessible. So if you want to stay up to date, revisit episodes, or share them with others who might benefit, make sure you subscribe to my YouTube. Thanks so much for listening. It would be amazing if you could follow me or subscribe because it will really make a difference to grow numbers, enable this to reach even more people. Thanks so much. Now back to the episode.

Dr Mark Horowitz: [01:18:27] There's so many things to say. I think number one, even before we talk about side effects, is how these drugs work. I think that's also worth talking about because, you know, people have presented these drugs as sort of solutions to their problems. And I think they're anything but. You know, the work of Jonanna Moncrieff is a professor of psychiatry, I think, who makes these things very clear. Which is, you know, there's two ways of thinking about psychiatric drugs. One is what she calls a disease centred model where these drugs, where drugs can reverse the underlying cause of a condition. So for example, an antibiotic is a good example, a valid example. You've got a pneumonia, you're coughing up blood, you feel terrible, antibiotics go in, they kill the bug and your coughing and your fever goes away. You know, fantastic solution. People present psychiatric drugs as if they're similar. You know, even the word antidepressant sounds a bit like antibiotic. It's going to go in there, get the depression, kill it, and you'll come out the other side. And these sort of explanations are often based around this idea of a chemical imbalance. People's depression is caused by a neurotransmitter imbalance in their brain and antidepressants will fix it. They'll increase serotonin is the drug, is the transmitter most talked about. People will feel better. And that sounds like a very neat solution. You know, who wouldn't take a, a transmitter that you're lacking. It sounds very plausible and safe. But of course, you know, that explanation is not based in good evidence. We don't have evidence that says that depressed people have low serotonin in their brains or in anxiety. It was really an idea, it has been put forward by scientists 60 years ago, amplified by drug companies. So it's sort of, you know, everybody in the street thinks that, but there is not evidence for it. So there's another way of thinking about how do psychiatric drugs work, which I think makes a lot more sense, which she calls the drug-centred model. Antidepressants, pregabalin, gabapentin, antipsychotics are psychoactive chemicals. They cross the blood-brain barrier. They affect the way that you think and feel. And that means that those effects are superimposed on whatever you're feeling. An analogy would be to alcohol. If you're an anxious person and you don't like parties and you drink alcohol, you feel less inhibited, more calm. Nobody would say that social anxiety is caused by an alcohol deficiency. Everyone understands that alcohol is being superimposed on whatever anxieties you have. And also when you stop alcohol, it'll leave your blood, your anxiety will come back. And if you use alcohol in the long term, you'll become tolerant to it. It'll have less and less effect on your body or you'll need more and more. And also alcohol is gonna have toxic effects on your liver, on your brain. And it might be very hard to stop. You'll get withdrawal effects. If you think about psychiatric drugs through that lens, everything makes much more sense. You know, what do antidepressants do, for example? When you ask most people on the drugs, they say they feel numb.

Dr Louise Newson: [01:21:12] Yes, totally.

Dr Mark Horowitz: [01:21:13] And what they're saying is the range of their emotions from very positive to very negative has been compressed into the middle. And if you're very panicked or anxious, you know, or low in mood, having the volume turned down from a 10 to a four can be a relief. But it's not the same thing as fixing the underlying problem. And you have to expect all the issues that come with psychoactive drugs, you're going to get tolerance effects over time, it'll wear off. There's going to be toxic effects, which we can talk about in a second. When you try to stop them, you get withdrawal effects because your body gets used to it, when you're trying to stop it, it's sort of screaming out for it. And we now know that antidepressants and pregabalin and gabapentin and quetiapine and all of these drugs can have severe withdrawal effects that can last for some people for months or even years, not just a week or two that would be a kind of small hiccup, but serious problems. And then talking about all the side effects of the drugs. I'll start with antidepressants, then talk about pregabalin and quetiapine. Well, there's a lot of overlap. Antidepressants cause emotional numbing, you know, I think that might be their main effect. But that's one of the main reasons people come to my clinic in America, Outro Health, and in the NHS, they say, I don't know who I am anymore. I don't know what I think about my partner or children. I used to like art, music, sport. I've lost interest. And so what might have been useful in the short term, five years, 10 years later, it's causing them significant problems in their life. There's sexual trouble. We know those things actually correlated, emotional numbing and sexual numbing are correlated. More than half of people on antidepressants experience diminishment of their libido, desire, ability to ejaculate, to have sexual pleasure. We also know that some people have that even after they stop. There's a question, this is called post SSRI sexual dysfunction. There's the question, does it come back? You know, some people, it can take years, but it's a really a concern. Weight gain is a big issue, not in the short-term studies, in the long-term studies that comes out as a clear signal. There is daytime fatigue, trouble sleeping, concentration problems and memory issues, even in healthy volunteers. There are not great long-terms studies on the physical health consequences of the drugs, but there are cohort studies that find it. In all the studies they find similar findings, people who take antidepressants are more likely to have strokes, falls, have bleeding risks, osteoporosis, cataracts, heart disease, and in some studies, they will die earlier. There's a big debate about the degree to which that is based on their depression or on the medications themselves. In studies where they try as much to control for those issues as possible, these signals still come out. So there is a concern that we know that these drugs, for example, affect platelets, and so bleeding risks make a lot of sense, as do strokes. So there are, these are not just benign drugs. When you're talking about pregabalin, gabapentin, I mean, those drugs have been referred to one professional psychiatry as benzodiazepines on steroids. I think that's a very good description because they work on a slightly different pathway, but you can block their effects by giving an opioid blocker, which means they're doing something similar to opioids. They're obviously a drug of abuse. They have money, they have a street value on the black market. So they are addictive substances. They cause dependence. They also cause memory and concentration issues. They cause tiredness during the day. They can cause weight gain. They all cause withdrawal effects. So many of the issues with antidepressants are probably even worse for pregabalin and gabapentin. And there's a sort of catch up that happens where benzodiazepines have a fairly bad reputation, I think appropriately, amongst doctors. One, because a lot of doctors were sued a generation ago. And they don't prescribe them very well. I think, in fact, GPs are quite sensible with benzodiazepines. Here, have it for a few days, not a solution to your problems. Then a new drug comes onto the market that has the exact same issues. In this case, it's pregabalin and gabapentin. And it takes independent researchers 20 years to catch up to say, actually, these drugs that are presented as having no major issues are addictive, do cause dependence, can be hard to stop, aren't that effective. By that time, the next group of drugs are coming out. And of course we have ketamine coming out now, which is sort of even more obviously a street drug. I used an analogy to alcohol before, but now I don't need to use an analogy because ketamine is a street drug.

Dr Louise Newson: [01:25:35] It's a horse tranquilliser as well, isn't it?

Dr Mark Horowitz: [01:25:36] There's an issue every few weeks in the BBC, there's an article about kids using ketamine more and more. And at the same time, we're presenting it as a medical treatment. And of course, it's going to get some people high because that's what ketamine does. But there are all sorts of consequences. It causes your bladder walls to stick together, you get ketamine bladder. The effect wears off. Some people become very disorientated by the drug. They're going to, you know, bigger doses cause the K-hole, but even smaller doses cause disorientation, it increases the risk of car accidents, of heart troubles. In the original studies that they got the drugs approved on, there was more suicides in the group given ketamine, because some people obviously have a very unpleasant experience. So we are giving out drugs with psychoactive properties to a whole lot of people, older people, young people, and some people may find it pleasurable, and a lot of will find it unpleasant. It'll wear off, it'll cause a whole of physical health problems for them. And it'll be very hard for many of them to stop. So I think we are handing people out medications without huge evidence of their effectiveness with significant issues down the track for long-term physical health problems and withdrawal effects without being told exactly what they're taking.

Dr Louise Newson: [01:26:52] It's really scary and people listening might be wondering why we're talking about pregabalin and gabapentin and ketamine but a lot of women with hormonal issues are prescribed these and I was actually horrified the first time I read some menopause guidelines that say they talk about non-hormonal treatments and you know there are lots of non-hormonal things we can do that aren't medicalised you know I do a lot yoga, that's irrelevant whether I take hormones or not, there's lots of mental health issue, improvements that can occur with regular exercise or going outside or whatever, eating, all sorts of really important things. But actually, in the guidelines, it says that gabapentin and pregabalin can be given for flushes and sweats. Now, firstly, flushes, and sweats are not the most common nor the most severe symptom. And actually, why would you give those highly addictive drugs? I was shocked, but we see people that have been offered and given them because they've been scared away from their natural hormones. It's just like, you don't replace one thing for another, but nothing that has all these awful side effects and risks.

Dr Mark Horowitz: [01:27:59] I can't speak to the exact studies in menopause because I'm more aware of the studies in depression and anxiety. But the sort of approach that drug companies normally take with these sort of things is they do short term studies. It goes for four weeks or eight weeks. And sometimes you see a small effect. And if you see small benefit, you don't know, there's lots of reasons why you could see a benefit. Maybe you're a little bit high. Maybe you are a bit euphoric because you've been given these drugs that can make people a bit high, maybe you're bit numbed and so you don't feel things as much as you used to. Maybe you're unblinded by the treatment, you've got side effects, that makes you think I'm on the treatment. We know that expectation effects make people feel better. That's a very big effect in antidepressants. It's gonna be an effect with pregabalin or any other drug. And so you get these small effects and then they polish the trials and they get their drug approved and enters guidelines. But of course, people don't take drugs for eight weeks. They take drugs for years or decades. So you don't know what's gonna happen down the track. And what we can see with people on these drugs long-term, it's a very different story. The drugs wear off, sometimes they cause negative effects. Just using the analogy of alcohol, you might think you're quite happy on a couple of weeks of alcohol. Down the track, you know that's not the case. People end up being miserable and anxious. I see that a lot. People getting worse on longer-term treatment. Mood and pain get worse on longer-term treatment because what happens in the short-term isn't necessarily affected in what happens the long- term. And then all these physical health consequences build up. And also you're also not getting to the root cause of what's happening. You're putting a sort of sticking plaster on top of it. And so, if they're doing studies in menopause that's anything like they do it in mental health problems. They're gonna be doing all these kind of tricks of the trade to make the drugs look effective in the short term, whilst ignoring long-term effects, the side effects, and often how small the effects are. I had a quick look at antidepressants and menopause. The effects are very minimal. I think they, you know, you can sort of, again, you need another magnifying glass. And yet, but they sort of get over the line of statistical significance at eight weeks and that's the trigger for getting approved and suddenly have a whole lot of drugs being given to a very wide group of people based on very scant evidence.

Dr Louise Newson: [01:30:02] Because more women are prescribed antidepressants than they are HRT. Just tell me the stats before we finish about antidepresant use.

Dr Mark Horowitz: [01:30:10] So, in England and Australia and America, about one in six adults are on antidepressants. So in England this year, nine million adults will use antidepresants. It's more common amongst older people and women. So women are prescribed antidepressants 50% more than men. As you get older, the gradient goes up. So it means that middle-aged women, I think that's defined as 40 and 60, about one in three in England are on an antidepressant. So it's very high level.

Dr Louise Newson: [01:30:37] One in three.

Dr Mark Horowitz: [01:30:38] I think in areas of deprivation, I think, in North England, it's even higher and it's increasing every year. So every year, there's a few per cent going up in part because people are on these drugs longer and longer, probably in part because it's very hard to stop them because of withdrawal effects. So people end up getting, I think that's another issue. It's very easy to start these drugs, much harder to stop then because you get to get dependent on them. And so there is escalating use all throughout the world.

Dr Louise Newson: [01:31:03] So we need to wake up, we need to think about it, we need to think differently before we start. And when I say we, I mean us as doctors, but also we, I mean, us as potential patients as well, or friends or relatives as well. I think it's really important that we look at mental health with a different lens, actually, and look at some of these medications and wonder what we're doing. But also, we just need to be thinking about other ways of managing any mental health issue. I think, you know, we're not talking in this podcast that everyone needs to come off their antidepressant overnight and actually please don't because, you know, it's important to...

Dr Mark Horowitz: [01:31:39] I should say that, sorry, if you do decide that medications are not for you, it's worth talking to your doctor. And coming off your drugs quickly is the worst possible thing to do.

Dr Louise Newson: [01:31:49] Absolutely.

Dr Mark Horowitz: [01:31:49] You get terrible withdrawal effects, so do it carefully.

Dr Louise Newson: [01:31:52] And that's why, you know, the de-prescribing guidance.

Dr Mark Horowitz: [01:31:54] That's we have the book and that's why we have the clinic.

Dr Louise Newson: [01:31:55] It's very important that people do it in conjunction with people who are experienced, you know of deprescribing, because the response can be very different and it can take a long time, but it's worth persevering. I've had some very good responses, but sometimes it can takes years and years.

Dr Mark Horowitz: [01:32:08] Exactly.

Dr Louise Newson: [01:32:09] So it's great. This conversation is just the start of many really for people to be thinking differently and making choices really. So before I finish, Mark, I always ask for three take-home tips. So three things that people will be listening to this and thinking, gosh, maybe I don't need that antidepressant. What are the three things they could be doing?

Dr Mark Horowitz: [01:32:32] You mean, instead of taking antidepressants?

Dr Louise Newson: [01:32:34] Yeah or just in general if they think or maybe I need to stop because I think there's two things really there's the deprescribing side but there's also like what to do instead as well because the two should work in parallel.

Dr Mark Horowitz: [01:32:44] So I'll say a few things, I'll try to keep it to three. I think number one, even before you get to alternatives, is the drug helping? I think one, a lot of people, the drugs are not helping, and for some people, they're making it worse. And so in that case, you don't even need a replacement. Just stopping something that's not helping you or making things worse is a good step. So I think it's worth really sitting down. I see people who think through, am I better than I was before I started all these treatments? And a lot people conclude, actually, I think that I'm doing worse after all these treatments. So I guess the first thing to think about. Two, I think a lot of people mistake the trouble they have coming off antidepressants with the fact that they need antidepresants. So people stop. They feel terrible, anxious, low in mood, panic. They think, I must need this drug. The GP reinforces that idea. So I think people should be aware these drugs cause significant withdrawal effects. They can feel like someone's condition coming back. They're often not. We know withdrawal effects are very common. So not to fall into that trap of mistaking withdrawal for the fact that you need the drugs. I think in answer to your question, there are lots of other things people can do that can help mood. I mean, I think number one, you know, I can, I'll rattle off all the things that the NICE guidelines say, but before you get to that, the most important thing is, you know what has caused you to be in that position because, you know, to say that you needed a drug, there's a chemical imbalance, it's a bit of a one size fits all. You know, some people are in you know bad relationships, some people are in difficult jobs, some people have physical health problems. And to sort of say, it's all the same thing, we'll give all the same treatments, doesn't make sense. I think the first thing is to work out, you know, why is there a physical health problem? Is there, is it a relational problem? Doesn't mean it's easy to solve. I don't, I'm not going to be glib and say, well, then you can just, you know, wave it over with a wand. But if you don't understand what's causing it, it is very hard to work out how to fix things. Then to get to things like the NICE guidelines, there's a whole lot of non-medication things that are just as effective as antidepressants in the short term. Some of them are more effective in the long term. And they're all safer. And it includes exercise, mindfulness, various forms of therapy. And I always like to point out is NICE says the most cost-effective treatment for severe depression is problem-solving therapy, which means writing down your three most significant problems, the first step to take for each one and report back on progress made or barriers encountered in two weeks. I think that really brings home that it's people's problems that are causing their mood. And I think we've lost sight of that. So I would put that sort of in people's minds to sort of demedicalise their condition.

Dr Louise Newson: [01:35:14] That's so important, such great advice, so thank you so much for coming today.

Dr Mark Horowitz: [01:35:18] Thanks Louise, appreciate it.