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Doctors are not trained in how to discontinue psychiatric drugs

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Tens of thousands of Europeans are every month seeking advice on how to discontinue or get off antidepressants outside their regular health services. That’s because doctors are not trained in how to deprescribe antidepressants and other psychiatric drugs research has found. The research suggest that tapering (slowly stopping) has to be done gradually, and at a rate that the individual user can tolerate, and reductions should be made by smaller and smaller amounts. It can take months and even years to get fully off the drugs.

Can not get off common antidepressants

At large international psychiatric congresses it for years has been common to present new studies on psychiatric drugs and discuss why and when to prescribe medications. At this year’s European Psychiatric Congress that was recently held in Budapest, Hungary a so-called State of the Art lecture set a new trend looking at how to properly discontinue or deprescribe psychotropic drugs.

An expert, Dr. Mark Horowitz a Clinical Research Fellow in Psychiatry at the National Health Service (NHS) in England had been given the task to address the necessary skills and guidelines to supported reduction or discontinuation of psychopharmacological treatment.

The backdrop to this is a scene in which many people cannot come off common antidepressants in the way the official medical guidelines recommend. Studies in Holland found that only some 7% of people could stop in this way and in England they found that 40% of people could stop in this way however with quite pronounced withdrawal effects.

Part of the problem is that doctors often believe that the withdrawal effects are “brief and mild”. And they do not know that withdrawal symptoms may include anxiety, depressed mood, and insomnia. The result is that they often tell their patients using antidepressants that there shouldn’t be a problem with coming off the antidepressant drug, and when the patients do report withdrawal effects they believe these to be the original underlying condition. A very large number of persons are due to this problem diagnosed as having a relapse (a return of someone’s underlying condition) and are being put back on antidepressants, sometimes for years or decades, or even lifelong.

Doctor’s advice unhelpful

The consequence of this is that many people who really want to get off the antidepressants leave their regular healthcare system and seek advice on peer support forums on how to come off their medications. Two peer support websites in English alone has some 900.000 hits a month, and almost half of them are from Europe.

There’s 180,000 people on these sort of websites. The research team of Dr Mark Horowitz surveyed 1,300 of them and found that three quarters of them considered their doctor’s advice was unhelpful. The story of many of them was similar. The most common tapering period that they had been recommended was 2 weeks and 4 weeks exactly like the guidelines of the public agency of the Department of Health and Social Care in England responsible for guidance, NICE, recommended, until it was updated recently.

Getting off antidepressants despite the doctors’ reassurances was a nightmare for many. Stories echo each other that the effects were so horrendous that the user had to get back on the antidepressant or otherwise would end up in a terrible state. The result is as many users expressed that “I’ve lost faith in my doctor.”

The underlying problem that has often been neglected is that years of use causes adaptation to the antidepressant drug and this adaptation persists for longer than it takes the drug to be eliminated from the body. That’s what causes withdrawal effects.

“When you stop the drug, let’s say months or years after the patient had been started on drug treatment following a stressful period in their life, the antidepressant is metabolized by the liver and kidneys in a few days or weeks. But what doesn’t change in a few days or weeks is the residual changes to the serotonin receptors and other systems downstream of this,” Dr. Horowitz explains.

In studies on humans, there are changes to the serotonergic system that persists for up to four years after the antidepressants are stopped.

The longer the harder

And the research indicates that the longer people are on the antidepressants, the harder it is to stop and the more severe the withdrawal effects.

For people who are on antidepressants for more than three years, in surveys two thirds are reporting withdrawal symptoms and half of those people are reporting symptoms that are moderately severe or severe.

“You can see clearly the more you’re adapted to a drug, the more difficult it is to stop it,” Dr Mark Horowitz explains.

And it is common as Dr Horowitz noted, “We have conducted a survey, of a group of people who are accessing therapy in the National Health Service (NHS) of England, two-fifths of them who have been on antidepressants have tried to stop and been unable to do so, and that correlated strongly with withdrawal effects.”

To minimize the risk of withdrawal effects, which more than half will experience using the commonly recommended procedures, certain principles about tapering antidepressants have to be known. The research indicates that the best approach to tapering is to perform it gradually (over months or sometimes years), and at a rate that the individual user can tolerate. Furthermore, it has to be done in smaller and smaller amounts.

Why tapering gradually

Dr Horowitz explained how to taper psychiatric drugs properly. Photo: THIX Photo.

Research using PET scanning on persons using different doses of antidepressants showed that the inhibition of the serotonin transporter doesn’t occur as a linear line, but according to a hyperbolic curve. This follows a pharmacological principle known as the law of mass action.

In more regular language, it means that as one adds more and more drug to the body’s system, more and more neurotransmitter receptors are saturated. And so, by the time one reaches a high dose, every extra milligram of drug has less and less incremental effect. And that’s why one get this hyperbola pattern. This pattern is true for all psychiatric drugs.

This explains why users experience problems in the last stages of withdrawing from a drug. Doctors in general practice have come to use an approach of linear decrease, like 20, 15, 10, 5, 0 mg.

Dr Mark Horowitz explains the findings not only from a neurobiological viewpoint, but very much how users have explained it, “going from 20 to 15 milligrams has a very small effect on the brain, 15 to 10 a little bit larger, 10 to 5 larger again, and going from 5 to 0 is like jumping off a cliff. You think you’re down near the bottom, but actually you’ve walked out the eighth story window, in my view.”

The first few milligrams are easy to come off, and the last few milligrams are much harder.

“When doctors don’t understand this relationship, they think people must need the drug because they’ve had huge trouble and they’re pushing people back on it,” Dr Mark Horowitz added.

Based on both neurobiological research and clinical observations it thus makes more pharmacological sense to not reduce drugs by a linear amount of dose, but to reduce drugs by a linear amount of effect on the brain.

The approach of reducing the drug rate so it causes an ‘even effect’ on the brain requires decreasing by smaller and smaller amounts down to tiny final doses. So final reduction from this tiny dose to zero doesn’t cause a bigger change in effect on the brain as previous reductions.

One could approximate this by talking about proportional reduction. So, for example, reducing by about 50 percent at every step, going down from 20 to 10 to 5 to 2.5 to 1.25 to 0.6 approximately causes even changes of effect on the brain. Some people will need even more gradual dose reductions – for example, reducing by 10% of the most recent dose every month, so that the size of the reduction gets smaller as the total dose gets smaller.

Caution on withdrawing from psychiatric drugs

In noting this Dr Mark Horowitz cautions, “It is important to say it’s very hard to guess what rate an individual can tolerate. As it’s something that can take two weeks or four years. That’s why it’s very important to take the approach of adjusting to the individual, making small reductions and seeing how they respond before deciding on further steps.”

If withdrawal symptoms become too severe, then the reduction should be halted or the dose increased until symptoms resolve and the reduction should then proceed to a slower pace.

In England the new NICE guidelines, which is not just for psychiatrists, but for GPs, recommends to slowly reduce the dose in a stepwise fashion, at each step prescribing a proportion of the previous dose.

For clinicians not only in England but everywhere there is now extensive guidance available. Dr Mark Horowitz has co-authored the recently published “Maudsley Deprescribing Guidelines”. It describes how to safely reduce every antidepressant, benzodiazepine, z-drug and gabapentanoid that’s licensed in Europe and America. The “Maudsley Deprescribing Guidelines” can be bought through the medical publisher Wiley and even through Amazon. A forthcoming version of the Guidelines due in 2025 will also include antipsychotic drugs and other psychiatric drug classes.

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Female circumcision in Russia – exists and is not punished

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Every year, millions of women and girls in the world are subjected to the procedure “female circumcision.” In the process of this dangerous practice, women have part or all of their external genitalia removed. Among the victims are also residents of the North Caucasian republics of Russia, and the Russian authorities do not punish the execution of the violent procedure.

How this violent religious-ritual tradition exists in modern Russia, do the authorities and the clergy try to fight it – reveals the Russian publication of Verstka.

What is “female circumcision”

Female circumcision is a procedure that is accompanied by either trauma or partial or complete amputation of the external genitalia. As a result of the procedure, sensitivity is reduced and the woman may lose the ability to have an orgasm.

Not for medical reasons

The procedure is not performed for medical reasons, but for ritual or religious reasons to suppress female sexuality. That is why in the international medical community this term is not used, but is called “female genital mutilation operations”. International law considers them an attack on the health of women and girls, a form of violence and discrimination.

Victims

Victims of female circumcision are girls up to the age of 15. According to data from the World Health Organization (WHO), in 2024, more than 230 million women in the world suffered from such operations. They are mostly carried out in African, Asian, Latin American and Middle Eastern countries. But there are also victims of female circumcision in Russia among the residents of the North Caucasian republics – Dagestan, Ingushetia and Chechnya.

Injuries

The procedure has serious negative consequences for women’s health – from serious injuries to death due to blood loss. In addition to physical trauma and the shock of pain, female circumcision disrupts the natural functioning of the body. Women and girls may suffer from infections, their genitourinary system may be damaged, they may experience pain during sexual intercourse, menstrual disorders may occur, and the risk of complications during childbirth and death of the mother and the newborn increases by 50%.

Why do they do it?

The “necessity” of such operations is justified by honoring traditions or religious motives. In some cultures, it is part of the rite of female initiation or entry into adult life. Female circumcision is often associated with Islam, including in the Russian Federation.

Prevents lust

In the words of Dagestan journalist Zakir Magomedov, “in the local religious press, which is issued by the official clergy, articles are published in which it is written that female circumcision has a beneficial effect on a woman and protects her from lustful thoughts and desires, and is even beneficial for a woman.”

Female circumcision is performed by people without medical training, and old pocket knives or cattle shears are used as tools.

Control over female sexuality

In almost all cases, the purpose of the procedure is defined as control over female sexuality: “not to be hoika”, “not to freak out”. The official clergy of Dagestan include female circumcision in religious duties, although it is not mentioned in the Koran. Some Muslims, in addition to the Koran, are also guided by the Sunnah – traditions from the life of the Prophet Muhammad and statements of authoritative religious figures. Therefore, in some cases, female circumcision among Muslims can be interpreted as permissible, desirable and even mandatory.

Officially, the Russian authorities are against it

“All women should be circumcised so that there is no debauchery on Earth, to reduce sexuality”, this is how the head of the Coordination Council of Muslims of the North Caucasus, Ismail Berdiev, reacted to the revelations of the “Legal Initiative” organization in 2016, which confirmed the existence of practice. Later, Berdiev clarified that “he did not call for female circumcision”, but only spoke about the “problem of debauchery”, with which “something must be done”.

The Russian Ministry of Health condemns the procedure, and the prosecutor’s office of Dagestan conducts an investigation and finds no confirmation of the facts presented in the report of “Legal Initiative.”

The deputy of the State Duma from “United Russia” Maria Maksakova-Igenbergs proposes to introduce the concept of “women’s discrimination on religious grounds” into the Penal Code, and that the punishment for “female circumcision” be 10 years in prison. The Ministry of Justice of Russia does not support Maksakova’s initiative, clarifying that the procedure falls under the Criminal Code of the Russian Federation, and more precisely under the paragraphs on “deliberately causing severe, medium and light harm to health, as well as causing harm to carelessness.”

North Caucasus

According to the “Legal Initiative” organization, in the middle of the last decade in Dagestan, at least 1,240 girls were subjected to the procedure annually. The majority of the men surveyed were categorically against the ban on female circumcision, explaining their motive not only with Islam, but also with local traditions and the desire to control the morality of women. Part of the respondents expressed an opinion against the procedure, arguing that the lack of sensitivity in women lowers the quality of sex in men as well.

And in Moscow

In 2018 one of the Moscow medical clinics announces the service of “female circumcision” for ritual and religious reasons for girls from 5 to 12 years old. On the clinic’s website, it was noted that “the operation should be performed not at home, but in a medical clinic.” After a wide public response, the clinic removed the information from its website, but an investigation was carried out, which found the existence of the procedure and other violations. A warning has been issued and the clinic is still open!

First conviction without penalty

Despite the fact that in its second report the organization “Legal Initiative” notes the disappearance of the practice in Chechnya and Ingushetia, the inhabitants of these regions remain in danger. In the spring of 2020, the father of a 9-year-old girl invited him to Magas (the capital of Ingushetia) for a visit and took him to a vaccine clinic. There, female circumcision was forcibly performed on the child. The value of the “service” is 2000 rubles. The little girl, in her bloodstained dress, was then put on a bus back to Chechnya, where she was hospitalized for severe blood loss. The father explains his motive as follows: “So that he doesn’t get excited.”

A criminal case has been opened against the gynecologist who performed the circumcision for intentionally causing minor harm to health. The case has been going on for a year and a half. The judge called on the parties to reconcile, adding that “the girl cannot be helped anyway”. In the end, the doctor was found guilty and fined 30,000 rubles, but was released from serving the sentence due to the statute of limitations. No criminal proceedings have been initiated against the clinic.

In the same year, the mufti of Dagestan issued a fatwa and recognized the removal of the external genitalia as forbidden in Islam, but clarified that “female circumcision” meant only hudectomy — the removal of the foreskin of the clitoris. This is also a crippling procedure, human rights defenders insist.

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Four executed for producing illegal alcohol in Iran

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Iranian authorities have executed end of October four people convicted of selling illegal alcohol, which poisoned and killed 17 people last year. More than 190 people who consumed the dangerous drink were hospitalized.

The death sentence against the accused in the case was carried out in the Karaj Central Jail.

According to human rights organizations including Amnesty International, Iran carries out the highest number of executions per year after China.

After the Islamic Revolution in 1979, Tehran banned the production and consumption of alcoholic beverages. Since then, the sale of illegal alcohol on the black market has flourished, leading to mass poisonings. The latest case, reported by Iranian media, has killed around 40 people in northern Iran in recent months.

Only Iran’s recognized Christian minorities, such as the country’s Armenian community, are allowed to produce and consume alcohol, but discreetly and only at home.

Illustrative Photo by Amanda Brady: https://www.pexels.com/photo/elegant-champagne-coupes-in-sunlit-setting-29157921/

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What is food neophobia – the fear of trying new dishes

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Everyone has heard of anorexia and bulimia. But these eating disorders are far from the only ones.

There are people around the world who can only eat certain colored foods. Still others are addicted to water. About 5% of women between the ages of 15 and 35 are affected by some type of eating disorder. Among them are those with neophobia – the inability to try a new type of food. This problem sometimes also affects young children. For them, experts advise parents not to force them, but to explain to them the benefits of a given product. It is also an option to put them on the table in the company of other children who will set a good example.

Neophobia usually disappears around the age of 6. For some people, however, it remains a problem for much longer.

A possible explanation for this condition could be something happening in the person’s life – like choking on food, for example. As a result, a person may begin to avoid a certain type of food and thus give his phobia a “field of expression”.

The reasons for neophobia may lie not only in the psyche, but also in physical features. This disorder is genetically transmitted.

Illustrative Photo by Chan Walrus: https://www.pexels.com/photo/white-and-brown-cooked-dish-on-white-ceramic-bowls-958545/

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