SSRI ELIMINATED

SSRI ELIMINATED

Musical instruments have a variety of mutes, from a fist inserted into the bell of a French Horn or a conical impediment to air flow from a cornet, to my violin’s device that dampens the vibration of the wooden bridge adjacent to where the bow stimulates each string. Not only do these mutes exist, but composers writing the finest music ever created knew when a dampened sound would offer a more desirable effect than the more common brilliance of each instrument’s more customary sound. Musical muting was neither normal nor abnormal. It was what the optimum sound required. And it could be applied and reversed in an instant.

Minds sometimes function better with muffling, though doctors and pharmaceutical chemists have not done nearly as well as composers. Extreme anger causes considerable harm when implemented, first to a victim recipient, then to the person who received justice from legal proceedings. Mania appears dramatic to anyone who has ever forcibly shaken the hand of a sham candidate for elective office attired in lurid orange badgering every passerby outside a public building. Obsessives could use some chemical restraint. So can people who try the patience of their doctors’ receptionists with repetitive phone contacts expressing a mind constantly tossing about verbal descriptions of their misery. And sometimes, instead of subduing, an endogenous mute needs removal to alleviate disabling depression or PTSD.

Medicines to rearrange our thoughts or perceptions restore function. But they restore function with some constraints on the mind and behavior, which at some future time may do better without that chemical cap. These agents, dominated by the widely prescribed Selective Serotonin Reuptake inhibitors, or SSRIs, which have restored so many to optimal social engagement by alleviating endogenous impediments, have been much more readily introduced than withdrawn. We know when somebody expresses verbal or psychomotor retardation. People obsessed with the unimportant with adverse outcomes from neglecting their more vital activities can be identified either by an experienced observer or by responses to targeted questioning.

Medicines intended for chronic conditions have a way of following the trajectory of the Roach Motel, the doctor checks them in but never checks them out short of a dangerous adverse effect. Antihypertensives, statins, hypoglycemic agents, and drugs for affective disorders become indefinite in their duration, though the specific agents may change with circumstances and new developments. Yet as we have learned with successful bariatric surgery, what was once judged permanent may not need to be. Moreover, as people live longer and prescriptions per capita become unwieldy, drug holidays or selective suspensions of polypharmacy often express thoughtful medical care.

My own SSRI citalopram has not been transferred from my 90-day pharmacy amber tube to my weekly pill reminder case with daily bins for about a month now. It is not my first discontinuance, maybe one of several short-term interruptions over a few years, each lasting a few weeks, but barring the onset of major depression mandating therapy, it is my intent that this be a permanent stoppage. My doctor concurs, though the decision on when and how was entirely my own, and not conveyed to her until a scheduled office visit a few weeks later when I requested her intake assistant to remove citalopram from the computerized medicine list. I have the advantage of being an experienced physician myself who over the years prescribed these agents when depression seemed to compete with what I was trying to offer to assist each patient’s endocrine condition. Though I often wrote the initial prescription for a very specific need, one usually falling through the cracks, subsequent management went to another physician, usually primary, with virtually no disagreement and withdrawal subsequent to my initiation. And at follow-up visits, medication lists always got updated, though since my focus was on endocrine care, whether the SSRI remained an active prescription usually escaped my recognition. As a result, I initiated many, particularly in the early years of Prozac and Paxil when primary physicians were often reticent to take this prescription initiative. As these drugs and subsequent agents became more widely prescribed, untreated depression amongst my new consultations became infrequent. Like the Roach Motel, I checked my share in, checked only myself out.

This month without my chronic SSRI of years duration brought a gradual cognitive and emotional adjustment. I only minimally tapered my medicine over four days by halving the dose with a pill cutter, then just stopped. No classical withdrawal symptoms though my sleep pattern clearly changed. Over the past year, I had adopted a common sleep hygiene protocol of fixed bedtimes and morning out of bed with considerable success. An iTouch watch buzz would signal me to arise at 6:30, though I was almost always alert before that. Almost never used an OTC sleep aid. Almost never went to bed before the assigned time, with lights out at the iTouch evening vibration. While I would awaken usually twice, I almost never had to go to my lounge chair in another room to do a mindless activity as part of a return to sleep protocol. Within a few days of stopping citalopram, my sleep pattern changed, more for the dark hours than the daylight times. I arose on schedule, tired more in the early afternoon, and rarely felt sleepy at what had become my customary time for lights out. I found myself more often than not fully awake at times I would have previously been asleep. Sometimes I stayed awake in bed, but more often I stayed in the recliner watching TV until I drifted off, typically two hours later. Despite being altogether alert, I did not direct this to purposeful activity from dishwashing to writing, or even reading. To my credit, though, I also did not use this added time wakefulness to respond endlessly to social media or check my email. Many years ago, I committed myself to computer screens shut down from 11PM to 5:30AM daily and held myself to this. Over the next few weeks, I reset the PM sleep time a little later, mostly recapturing principles of sleep hygiene, though less fully adapted than I was when taking the SSRI each evening.

More than anything, my disposition changed for the worse. Peter Kramer in his best seller Listening to Prozac, written within a few years of original FDA approval, described a patient with Obsessive Compulsive Disorder who received this medicine for its therapeutic purpose but also acquired a beneficial effect beyond the original intent. She became more socially personable. So did I when medicated. Irritations bothered me less, I was more patient with people, my comments less pointed and less abrasive. I recognized this with previous attempts at withdrawal, returning to treatment on my own when I perceived my wife preferred the medicated version of me. This happened again, though I remained more restrained in what would previously have been impulsive responses or snappy verbal barbs. I had already been married some thirty years before beginning treatment. If my unmedicated self could get me past courtship, successful child rearing, and professional achievement, some of the sacrifice of artificially enhanced social graces or disposition would not cause a major interpersonal hardship. It hasn’t thus far, though I tend to respond a bit more abruptly, even harshly, when provoked by my synagogue, some annoyances with my electronics providers, or my own thoughts on occasion. Easily angered, easily placated seems by endogenous personality. I do not feel obsessional at all. While never clinically depressed, I can sense an occasional sad day, well within my ability to adjust.

What has changed for the better may be the vividness of my senses. The retina is the same but the CNS visual interpretation registers as brighter. My language acuity, the ability to shift from one frame of reference to another in response to what I hear or read seems not only different but brighter. I perceive myself as either more playful or wanting to be. When I drive, I seem to generate more pleasure when I look around. It is as if my senses were partially stifled, but no more. I feel more inclined to rebellion, more critical of what I encounter that registers as could be better, though in a way that defaults to jocular, never hostile. The world seems to sparkle more. The Intelligent Designer, or Mother Nature, did not compose this part with a mute.