Ending Antidepressants I

An interview with Dr. Mark Horowitz of Outro Health

Readers of The Frontier Psychiatrists—today’s article is part one of an interview, with some light editing, with Dr. Mark Horowitz, MBBS, Ph.D., a psychiatrist and co-founder of Outro Health. I’m an advisor to that company. They exist to allow patients to taper off of antidepressant medication safely. I’ve written about the lack of efficacy in these drugs before. For example, in my book Inessential Pharmacology. (Amazon link). I've got three other physical books already, two of which are poetry, the least commercial art form on earth. One is a therapy manual published by Springer Nature. Mark’s book is the Maudsley Deprescribing Guides.

Part one is available here and you are reading it now.

Part two is available here.

Part three is available here.

Mark Horowitz, MBBS, Ph.D.

MH: So, look, I'm originally from Australia. I grew up in Sydney. At the age of 17, I made a very ill-informed, immature decision to embark on a medical degree. I decided to add on a double degree. I earned a degree in philosophy of medicine and decided to add on a psychology degree. I've got an issue with degrees. I think, you know, four is good, two might be impressive, but six is pathology.

OM: I'm guessing you would advise against that now?

MH: I strongly advise against it. There are better addictions to have. Much cheaper. I advise you otherwise regarding both finance and time spent.

OM: The earlier you start the process of pursuing multiple degrees, the more likely it is you'll become addicted. (laugh)

MH: I'm a hardcore student. At some point, I had to tell people to block me from enrolling in another degree. I moved to London 15 years ago for a master's and a PhD in neuroscience and psychiatry. I was very interested in understanding the brain to make sense of depression and how antidepressants worked.

OM: Why London?

MH: In my early years, someone told me, “The best place to do psychiatry in the world was the Maudsley Hospital in London.” I'm a British citizen as well. My mother was born in Scotland because my grandparents escaped from the Holocaust.

Maudsley is a hospital that happens to be next door to the Institute of Psychiatry, the most prominent research institute for psychiatry in Europe. That's where I did my PhD, at the Institute next door.

I did a master's in neuroscience for a year, where we went around different labs, and then I chose a lab to complete my PhD. It was with a professor of biological psychiatry called Camino Pariante. I did it for about three years. I looked at the biology of depression. We used human brain cells in a dish, and we tried to simulate depression by adding stress hormones and inflammation and looked at the effect of antidepressants and whether they could reverse that process or not. This is an area of research that I now see as ridiculous.

OM: And when you say you '“now see it as ridiculous,” describe how you could have missed that at the time?

I think that I was profoundly drinking from the Kool-Aid that is everywhere, especially in America, that by understanding the brain, we will understand mental health conditions.

MH: You understand why people get rapidly beating heart and chest pain by understanding the physiology of the heart. That makes sense. There's an analog thought that we'll understand mental health conditions by understanding how the “brain works.” Understanding neurons, synapses, and neurotransmitters is the level at which to understand mental health conditions. I think that's the animating kind of theme of modern psychiatric research. I think that's ridiculous now. Mostly because I think it's premised on a category error. Because I believe that, essentially, people are miserable or anxious because of what happens to them in their lives, at least most of the time. Trying to understand that at the brain level is like trying to understand why a software program is broken down by looking at the hardware in the back of the computer. Yes, in one sense, all software issues exist in the hardware; that's true. Without the circuits, you can't have any software. But when software goes wrong— do you open up the circuit board and solder? That doesn’t make sense. There have been so few insights developed by looking at neuroscience to understand mental health conditions. However, there is a huge relationship between social circumstances and people's mental health symptoms. I spent years looking at nerve cells to understand human emotions. So, of course, my name is on several papers that came out of that lab. Most of them are null findings, I should say. I don't think anything of great help to any human being came out of that lab.

OM: What moment did you have the insight you're describing now that you felt biological science would not yield fruit?

MH: It was not until years later. I want to claim that I came to these insights through being clever, thoughtful, introspective, or anthropologically minded, but I'm not so clever. I came to become critical of the paradigm of biological psychiatry, not through any intellectual work, but because I almost died from the treatments that a psychiatrist gave me.

Well, it wasn't prescribed by a psychiatrist. I didn't see a psychiatrist until late in my career as a person taking psychiatric medications. When I was 21, I was a very miserable young man. If you've ever seen a Woody Allen film, I came from a family, a family like those films portrayed, I was very uncertain about life. I went to see a GP, I think what's called a primary care physician in America, and like one in two people, I was offered an antidepressant. It happened to be Lexapro.

The generic name is escitalopram, which is the most popular antidepressant in Australia these days. And they came onto the market a few years before I walked into my GP's office. I was given a starter pack from one of the drug companies. I took that for many years.

During medical school, during my training in psychiatry, and my Ph.D., I took this medicine. I guess there are two major effects it had on my life. Number one, I had a lot of health problems while I was on the medication. They were profound daytime tiredness and fatigue. Later, memory and concentration problems developed, and these increased over time.

As a younger man, I had a brilliant new photographic memory. As time went on, my memory and concentration got worse and worse until they became quite bad. It was quite pronounced and quite worrying, and it had a big effect on my ability to function well. It became quite embarrassing, forgetting things quite often. Most of the time, it was daytime fatigue.

OM: was lexapro the only medicine you were taking at the time?

MH: Yeah, for many years, I took just Lexapro escitalopram.

OM: My, my level of envy to hear that statement! I have bipolar disorder. Polypharmacy has been my life — then, I developed an autoimmune condition thereafter. So if there was a thing to blame, you knew which one.

MH: Well, it started as the only one for the first 10 years, but it didn't end up as the only one I ended up on, on five different drugs.

OM: Oh God.

MH: In retrospect, it was a prescription cascade. What happened was I was very tired. I would fall asleep during class. Eventually, a professor said, “This is very strange. You keep falling asleep every in every lecture.”

He sent me to a doctor. I was diagnosed with narcolepsy, type two narcolepsy.

OM: You had an MSLT for that? [ed: this is a medicine abbreviation for “multiple sleep latency test,” the gold standard for the diagnosis of narcolepsy]

MH: I had several of them, um, and that was positive, and so I was given a diagnosis of narcolepsy, and because of that, I have prescribed stimulants of various forms over the years, Ritalin, modafinil, and essentially what happened over time drug side effects, which accumulated more drugs. So, because it made me anxious, different and more drugs were added. Because it made it hard to sleep, different sleeping tablets were added. So, at the height of my career as a psychiatric patient, or I guess you could call it a neurological patient also, I was on two antidepressants, mirtazapine, escitalopram, methylphenidate, and Zopaclone. The next one—and the last drug I was on—was gamma-hydroxybutyrate or Xyrem.

I started off on five drugs, I've come off four of those, and I'm down to the last little tiny, uh, bit of mirtazapine is the last drug that I'm on, I'm just a quarter of a milligram, so a little speck of a drug.

I guess in coming off those drugs, one of the main things? All those symptoms I experienced have resolved. Daytime fatigue, memory, and concentration issues. Although I'm not back to being the 20-year-old that I was— I certainly don’t have anything like the level of impairment I had on all these drugs. I was impaired to the degree that whilst I was on these drugs, I worked only part-time because I was so fatigued.

OM: Oh my God.

MH: I've returned to full-time work. There was a point at which I was so impaired that I thought it was unethical to keep practicing as a doctor because I would write down everything that was said to me. And if I lost my piece of paper, I'd forget things. If someone asked me, “How was that patient you saw two days ago?”

I could barely remember who they were talking about. I reached the point where I thought it was unethical to keep practicing like this, and I could still take medical retirement. It was quite impactful on my life. I am getting back my ability to think straight. Being energetic during the day has been an incredible gift to me. I feel like I've been given a second chance at life. So that's the first aspect. The second aspect is the bit that almost killed me.

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Thanks for joining us for part one of this interview! Stay tuned for more.