I wrote all my passwords on an envelope next to my computer. I wasn’t sure I would survive, and I wanted my brother to be able to log into my computer and websites. Suicide had never been an issue for me. My particular depression never included thoughts like that. It was a complete shock when they intruded on my thoughts and started to sound plausible. Intellectually, I recognized that it might be caused by lowering my daily dose of Paxil, but I couldn’t separate my thoughts enough to see where they were coming from. Self annihilation clung to memories and old guilts so that they entered my conscious mind together. I had to sit and examine each feeling until I could pin down what was real and what was an imbalance. I knew my Serotonin levels were fluctuating and that would have significant impacts on my mood, but that knowledge was a bare comfort when I sat at my desk crying.
It’s hard to describe how powerful the effect is without experiencing it. I started losing a lot of weight, but the fact that my pants were falling off didn’t make me happy, it made me frustrated and mad. A rational person won’t understand the frustration I felt whenever I had to pull up my pants… I don’t understand it, now that I’m looking back at it. That was the most important thing to me for about two weeks. Each time I walked out of my pants, I’d yell at the walls, stomp around the room, I even yelled at the dog once. I put a big dent in my living room wall because I kicked it three or four times before I could cling to a doorframe and regain control. I’m a peaceful person, I’ve been in two fights in my life, 4th grade and 8th grade. I couldn’t stop kicking that wall for a second, though.
I wasn’t trying to wean myself off of Paroxetine in a vacuum. I saw my doctor regularly, I was in contact with my family, I had support from friends on the Internet. I read about possible withdrawal symptoms before I attempted to lower my dosage. None of that helped me endure the process. At first, I tried to take my daily dose with intervening days. I wanted to establish an every-other-day routine because I knew that I would be cutting my 40mg pills into smaller and smaller segments by the end. I didn’t think I could scrape 2.5mg off that big pill every day. I talked to my doctor several times about prescribing smaller pills. Those conversations never went past the initial request, though. Instead, he tried to convince me to continue my regular daily dosage. He offered to supplement my prescription with samples and low cost pharmacy alternatives. Eventually, he prescribed new pills that he intended me to take while I was weaning myself off of Paroxetine. After researching the new prescription, I found that it’s contraindicated with some Serotonin Reuptake Inhibitors and has a new set of side effects, including withdrawal symptoms. I don’t think that my doctor was trying to cause an adverse reaction or that he was necessarily incompetent. I was presenting him with symptoms and problems that he wasn’t trained to deal with. Most of the doctors I’ve seen have been trained to see chemical and surgical intervention as the two pillars of modern medicine. He seemed genuinely taken aback when I first told him that I was going to stop taking Paxil. From a patient’s perspective, doctors’ offices are filled with Pharmacon advertising. I sign in with a pen advertising bladder pills, I sign out with a pen advertising liver pills, and the back office is filled with brochures and sample packs. I don’t think it’s unusual that the first solution a doctor thinks of is one of those pen pills.
There’s also the issue of corporate reporting and training. Glaxo Smith Kline was recently forced to admit that Paxil can cause suicidal ideation in teens. I think the issue extends far beyond that small group of patients, but I only have anecdotal conversations with other patients to support the idea. Each patient I’ve talked to who is stopping Paroxetine treatment has experienced some form of renewed depression not associated with their previous diagnosis. That’s the most difficult thing about judging the adverse effects of an antidepressant. It’s very hard to separate the original symptoms from the ones caused by the drug. The company literature goes to great lengths to minimize those side effects, which complicates the issue. Each side effect is couched in retractions and stipulations until a rational reader would assume that they only affect a tiny minority of users. This gave me a false sense of confidence when I started my withdrawal process. I believed that it would be a relatively simple process, with just a few short term side effects that I could easily manage. Instead, I’ve been dealing with these symptoms for six months. It’s only now, at 2.5mg/day, that I can see the end of it.
The line of least resistance would have been to start taking my normal dosage again. There was something deep inside me that kept me on track to wean myself off Paxil, something that I can’t completely describe. It was a sense that my life had been put on hold for 10 years. Paxil suppresses a lot of mental activity, both constructive and destructive. Paxil was suppressing more than just my particular symptoms of depression, it was also suppressing the mechanisms that would allow me to progress towards resolving those issues. I tried Directed Talk Therapy, social workers, Cognitive Behavioral Therapy, I even sat with a Jungian type psychiatrist for a while. I didn’t have a visceral sense of the issues that I was trying to deal with, though. I felt disconnected from my emotions in a way that disrupted the therapy process. It wasn’t until I was forced to examine those hurtful memories that I realized where they originate from, and what role Paxil had played in suppressing them. I couldn’t really deal with those issues until the level of Paxil in my bloodstream started to diminish. At that point, I had to deal with my existing problems, as well as fluctuating Serotonin levels. That complication changed the nature of my recovery. Instead of dealing with a lifetime of issues over the course of several years, they flooded down on me in the space of six months.
Emotional suppression may be at the core of the Paxil withdrawal problem. In our society we belittle mental issues, treating them as weaknesses or character flaws. That’s not the nature of mental illness, though. It’s a real medical issue, just like a torn muscle or a concussion. I spent a year working in a place where I was responsible for a system, but had no authority over that system. At the end of that year, I had an uncontrollable tremor in my right arm, and a breakdown of sorts in the Human Resources office. I was put on medical leave for six weeks. I kept the shades drawn and the lights out for the first two weeks. I really felt that I had broken something in my mind and it hurt just as bad as a broken leg. Our minds create our reality in a fluid and transient way so we can’t see when something is wrong because that becomes our new reality. Paxil enhances that sense of mental relativism. A temporary depression, whether it’s caused by a neurotransmitter imbalance or an existing issue, is perceived as a long term or permanent problem. Imagine someone thinking about their life, and realizing that the way they feel today will be the way they’ll feel forever. It’s not necessarily true, but it Feels like it’s true. Without a healthy context to compare those emotions to, they take on a permanence that they shouldn’t in our minds. The compounding effect of Paxil, and its suppression of a broad range of mental processes, makes that kind of introspection much more difficult.
I’ve experienced nearly all of the withdrawal symptoms that company sponsored studies claim affect only a small minority of patients. The disparity between the claimed side effects and my personal experience leaves me with a profound distrust of Pharmaceutical companies. I don’t want to broadly characterize Pharmaceutical companies based on an anecdotal experience, but it’s hard to differentiate between my own internal feelings and justifiable anger. Just as mental relativism makes a small problem seem much larger, the disparity between the predicted effects and my own experience leaves me with an abiding sense that I’ve been lied to. I recognize that some of those feelings are strongly linked to an existing condition I have, but it’s more profound than that.
My sense of outrage hasn’t diminished over time, but it has changed. I don’t think that corporations are trying to make money off my depression, but I do think scientific studies that would illuminate these problems have been sidelined or minimized. The very nature of company sponsored studies make it impossible to be certain without inside information. Patients like myself are left with their own feelings and sense of mental stability. It’s the nature of the business that these drugs are used on patients that do not have a strong sense of self; it’s one of the symptoms that Serotonin Reuptake Inhibitors are designed to help. The irony is that the drugs themselves dissolve the boundaries between meta cognition (a person’s sense of their own thoughts) and random thought. I think that the development of Paxil stopped or slowed down once a formulation with any sort of efficacy was found. The fact that the effect is very broad was seen as an asset rather than a detriment. In the case of depression, that broad effect can be a very limiting factor, making treatment and resolution much more difficult for the patient. Pharmaceutical companies are trending towards broader applications of their drugs and less scrutiny from the government over the effects. Medical science has always been about developing techniques with finer applications and results from treatment. This new trend of marketing drugs to a wider audience doesn’t benefit the patient or their course of treatment. The company benefits financially, but that’s only half of their business. Mental illnesses are the most nuanced diseases that humans have thus far tried to treat. Using broad acting drugs on these very specific problems isn’t the best solution. Flooding the brain with “feel good” neurotransmitters masks symptoms rather than allowing the patient to safely address their specific illness.
One of the nuances of Paxil withdrawal is the way that changing the dosage affects the patient as much as the total dosage. In my case, even small changes in my daily dosage caused large mood swings. It didn’t seem to matter if I was going from 40mg/day to 30mg/day or 15mg/day to 10mg/day. For me, it was the change in dosage that initiated withdrawal symptoms, not the total dosage. Once I was stable at a new level, my symptoms diminished until I tried to lower my dosage again. There is a point where a large daily dosage of Paxil will overwhelm the brain’s Serotonin regulation mechanisms and cause its own problems. There are only anecdotal reports to support the idea that large amounts of Paxil cause mild overdose conditions, but the people I’ve discussed it with uniformly report the same effect. Artificially controlling Serotonin levels in the brain creates a dependance on the drug where the brain tries to regulate levels at the old level, but is confounded by the flood of neurotransmitters. As the drug builds up in the body, the brain no longer has to produce Serotonin at the previous levels. Once the patient tries to lower their dosage, the brain requires some time to ramp up neurotransmitter production again. This discrepancy leads to large fluctuations in the level of Serotonin, and withdrawal symptoms.
I started taking Paxil without knowing its effects or side effects. I described my symptoms to my doctor, he prescribed Paxil, and I started taking it. There was no discussion of the effects beyond “It will make you feel better”. Looking back, that reason was insufficient. Paxil has been a significant part of my life for a decade, influencing me in both positive and negative ways. I don’t regret starting the treatment, I didn’t understand the foundations of what I was feeling. I always thought that depression sprang from some unknowable source. Now I know that there are discrete sources for depression. Each time we experience something new we use previous memories to evaluate it. If a child grows up with criticism and no sense of self worth, they will apply those experiences to new encounters as an adult. Constructive advice becomes a personal attack. Without a concrete idea of the foundations of that misconception, there’s no basis for a person to separate the older memory from the new experience. Paxil is a valuable tool, but it seems incomplete and ill used by modern medicine. Instead of recognizing the limitations of the treatment, the emphasis is on expanding its use with little regard for the pitfalls.