Inevitably, when you write a book about a growing global concern like antidepressant withdrawal, people reach out with questions. And even though I’ve received hundreds of inquiries in the year and a half since MAY CAUSE SIDE EFFECTS came out, I haven’t bothered to create an FAQ. As much as general themes repeat, people’s stories are unique, and canned answers rarely come in handy.

Instead, I try to answer each person individually and at the very least, ensure that they feel heard for a moment. In most cases—80%—this is all that’s needed. When people have been gaslit by doctors or have spent the majority of their lives under the influence of powerful psychiatric drugs, sometimes the difference maker is nothing more than someone validating their experience. That little bit of encouragement is enough to keep them on course and usually, I never hear from them again.

The remaining 20%, like all 80/20 relationships, take up most of my correspondence time. Typically these are the more complicated cases, usually from folks whose friends likely describe them as “a little neurotic.” These are the overachievers, the philosophers, the Type-As control freaks who did not schedule antidepressant withdrawal into their five-year plan.

This phenotype wants to do everything in their power to make withdrawal go away as fast as possible and can be found furiously googling and going down unhelpful rabbit holes on withdrawal forums. They also usually have money—depression is a privilege as it turns out—and are willing to spend it if they only knew what tests to get.

Of course, their doctor doesn’t have a clue, so when a basic blood panel comes out clean, the prescriber dismisses the idea of running more tests. The patient, though, knows something is amiss. Inn googling, these people find me and fill my DMs, which leads me the meandering point of this issue: every medical test I’ve been through to heal myself after fifteen years of antidepressants.

I took my last antidepressant in 2016, considered myself fully through antidepressant withdrawal in 2018, and spent the better part of 2021 – 2023 healing my body from the ordeal. I spent 2019 and 2020 tinkering with my diet in hopes of figuring out what was causing my gut issues and general I-feel-like-shit issues. I cut gluten or dairy or coffee. I ate less protein. I ate more protein. I juiced celery and drank fennel tea. I went to gastroenterologists who looked at me over a clipboard and said, “We can schedule a colonoscopy?”

Finally, in 2021, I called Andy Galpin, PhD., an old friend who, along with nutrition savant Dan Garner, was working with professional athletes to heal their lingering issues and improve their physical performance. Dan & Andy let me go through their program, which kicked off a two years of lab work and serious dietary changes that have finally allowed my body to heal and perform its best.

(I’ll cover my diet and the results of these tests in another issue. I’m on the road doing press for the paperback release of MAY CAUSE SIDE EFFECTS.)

Over a two year period, I’ve spent well over $10,000 out of pocket on lab tests. It is no small amount of money, especially given my super-lucrative career as a freelance writer and chef. (I recently received a royalty check for the amount of thirteen cents!)

Insurance hasn’t covered a dime, and still, it’s the best money I’ve ever spent on myself because I actually feel better. The key is to get all the testing done in a 1-2 week time period so you have a full picture of your health, all at once. This allows for the Dan Garners of the world to connect the dots between the body’s different systems, rather than isolating the endocrine/gut/blood labs in a vacuum and assuming nothing is connected, like allopathic medicine likes to do.

So, have at it folks. Go forth and figure out your shit. Literally.

Food Sensitivity:

MRT test

Hormones:

Dutch Test

Gut/GI:

GI Map

Heavy Metals:

Doctor’s Data Toxic & Essential Elements: Hair

Genetic:

GeneSight

Blood:

Complete metabolic blood panel

HNK1 (CD57) panel

Microscopic examination

Urinalysis, complete

C-Reactive Protein, Cardiac

Ferritin

Fibrinogen Activity

GGT

Hemoglobin A1C

Homocyst(e)I’ve

LDH

Lipid Panel with Chol/HDL Ratio

Magnesium

Phosphorus

Reverse T3, serum

Thyrogobulin Antibody

Thyroid Peroxidase TPO Ab

Thyroid Profile II

Thyroxine (T4) Free, Direct

Triiodothyronine (T3), Free

Uric Acid

Vitamin D, 25-Hydroxy

For months, I’ve felt like I just got on one of those carnival rides where you sit down, strap in, and let a rusty elevator take you to the top of a tower. Even though the elevator is gently taking you away from familiar ground, you know that at some point, the elevator will stop, open its doors, and give you a view of the world you’re about to drop into. And then, just as you relax into the view, the floor will fall away and gravity will take over, leaving you with no option other than to feel the rush.

I keep waiting for the elevator doors to open and show me a new world. It is coming. I can feel it and I’ve been feeling it for months. In October, I lost my main client and most of my work evaporated overnight. I challenged myself to simply wait, as itchy as it was because I could feel this something coming. I could feel myself standing in line, putting on a seatbelt, and waiting to move.

Every few years I seem to come back here, to a place of uncomfortably long stagnancy with no clear direction. The last time this happened was in August 2017. I was at the tail end of both a year of international travel and a year and some months of antidepressant withdrawal. I didn’t have a job or an address, but I had signed a flimsy book deal for a book called LADYBALLS. Though I still love the title, that book never came to be, but its existence contained the zygote of what would eventually become MAY CAUSE SIDE EFFECTS.

On a rooftop in Buenos Aires, I wrote myself a letter and dated it January 1, 2018. Why I thought six months was an appropriate open date, I don’t remember. But I do remember that when the new year rolled around, I looked at the unopened letter and knew it wasn’t time to read it. Days before, the book deal for LADYBALLS fell apart. I fired my agent and my publisher in a blind move that turned out to be the best career decision I’ve ever made. I couldn’t remember the specifics of the letter, but I knew if I opened it, I would only feel frustration and shame. So I stuffed it in a folder and forgot about it.

Until yesterday.

My strategy for dealing with general overwhelm is to spontaneously deep clean my home. Typically, a stressor appears—good, bad, doesn’t matter—and within a day, I decide my house is unacceptable. I am already known to vacuum in the middle of a dinner party, but this takes it to another level. In the words of Monica Gellar, the compulsive chef on Friends: “Not just health department clean. Monica clean.”

Yesterday, I signed a contract with a new client, thereby imbuing me with all sorts of problems to solve. After attempting—and failing—to solve all those problems in one morning, I came home and began scrubbing the screws on my toilet. Which led to re-lining drawers. And going through my closet. And cleaning out my desk, where I found a brittle, unopened yellow envelope dated January 1, 2018.

I smiled, sure that inside the letter was something about a $50,000 book deal that never materialized. Enough time had passed and I figured I could handle whatever was in there, even if what was in there was nothing but disappointment.

The back side:

I chuckled at the line, “By the time you read this, you’ll know where you’re going to live.” That is the only bit in there that isn’t quite settled. Something on the carnival ride feels like I’m not staying put much longer.

Everything else, though, has manifested. I wrote the book. And it’s good. And I finished on time, and I am happy with the words I wrote and the things I believe. The money came, too. And that independence. Real independence, because that year and these years gave me the gift of confidence and a voice—a true voice.

By the time I opened this, I had an address to come home to. And I can pay for it. And I am surrounded by people who love me. The negativity that followed me is a distant memory. I am me. And I am paid to be me. I am content, happy, full, and free.

I can’t remember if, when I wrote the letter, I really believed any of it would come true. I knew I wanted to believe, and that I’d seen glimpses of light during antidepressant withdrawal that at least taught me I was capable of experiencing a life I never imagined.

I share this with you because I can feel that I’m reaching the top of the elevator and that when it opens up and the ride truly begins, I know my story is going to reach even more people. So far, I’ve been able to keep up with the amount of correspondence I receive from people suffering from antidepressant withdrawal. Sometimes it takes a while, but I get there. I don’t know how much longer I’m going to be able to respond to everyone.

So, for everyone who is suffering, let this letter serve as an example of possibility. This can be your future if you keep the course and keep doing the work. Most times, the hard way is actually the easy way. Let it be hard. Feel it. Process it. Because at the other end is light.

Light

Light

Light

Light

Light

Light

Light

Joy

Love

Acceptance.

I awoke this morning, on New Year’s Day 2024, from one of those deep sleeps that makes you wonder if you ever really sleep at all. I have been sick for the better part of the holiday season, in every sense of the word—physically sick, heartsick, lovesick, grief sick, job sick—and most of my nights have been fitful, either because of a hacking cough or the prickly agitation that comes with the sort of longing that NyQuil can’t shake off.

The chest infection combined with other people’s holiday obligations meant that I spent most of the back half of December alone, an experience I am deeply familiar with after years of working in the Manhattan restaurant industry. In food service, someone has to work the Christmas Eve rush, frost New Year’s cupcakes, and cater Thanksgiving dinner to folks who don’t cook. Even if the business is closed on the actual holiday, someone has to work the day before and after, rendering cross-country travel impossible.

Thus, my clearest holiday memories are not of cozy, matching pajama-clad mornings, but of a Christmas dinner of Caesar salad and buffalo chicken wings at the Jewish diner underneath my apartment, long walks with my dog down silent Manhattan streets, the deep sense of toska pulling at my heart.

Goddamned toska.

A Russian word with no English equivalent, Vladimir Nabokov said it best: “At its deepest and most painful, it is a sensation of great spiritual anguish, often without any specific cause. At less morbid levels it is a dull ache of the soul, a longing with nothing to long for, a sick pining, a vague restlessness, mental throes, yearning. In particular cases it may be the desire for somebody of something specific, nostalgia, love-sickness. At the lowest level it grades into ennui, boredom.”

Perhaps, given my pockmarked history of holiday experiences, I am primed to feel the weight of toska each year. Or, perhaps this is something experienced by those who have lost a core member of the family. The holidays, for all their cheer, will always be a quiet reminder that my father is not around to throw a tantrum over tangled Christmas lights. Or maybe it is the mark of adulthood, when the magic of the morning is tempered by all the work it took to create it, and all the impending work it’s going to take to erase it.

But the stupid heart always has hope.

This year, while a campy holiday Hallmark movie chirped in the background as I loafed prone and achy on my mother’s couch, we talked about uncertainty. My illness, it seemed, was the physical manifestation of everything I don’t know going into the new year. And I don’t know anything right now.

I have had a sense, for months, that big change is coming to my world. And yet, there is no indication of what that might be or where it might take place. All I know is that in October, my income evaporated when a client’s situation changed, and since then I have watched lead after lead dry up while I anxiously monitor my bank accounts.

My heart, too, is searching for a signal, but the frequency I put out keeps getting lost in static. And yet I cannot shake the situation, the person, and how their existence in my life has fundamentally altered my perception of myself, my abilities, and what I want to experience in the world.

Meanwhile, in my Instagram DMs, a woman reached out to tell me that after 16 months of tapering, the last night of the year would also be her last time taking an SSRI. I reposted this on my Instagram stories, thrilled to get a bit of good news given that most of the messages I receive are of the opposite ilk.

The post gained attention, at soon folks were messaging me with other antidepressant withdrawal wins. One woman went to her first concert in four years, armed with earplugs to combat withdrawal-induced noise sensitivity. Another shared a story about her first trip to the grocery store after coming out of Zoloft withdrawal. Another recently gave birth to a healthy baby fourteen months after horrific Effexor withdrawal.

These little messages, most from folks who’d contacted me in the depths of suffering, lifted me not because of any hand my work may or may not have had in their healing, but because it reminded me that blind conviction is a requirement during fallow seasons. The other side of toska is hope. It is hope that lets us endure the pining, restlessness, and yearning for the magic to return, for the static to clear, and for the body to find health and equilibrium.

And so I awoke lighter this morning, the pull of toska not quite as heavy, the phlegmy cough a little less rough, with a little more patience to let the signal of work and love travel to their receivers.

Bestill the stupid, stupid heart.

The act of reading—specifically sitting down with a physical book or Kindle—tells me a person has the ability to focus, slow down, and live life with intention and curiosity. Whether they read fiction or nonfiction, sci-fi or biographies, they are likely to contribute to conversations and process ideas that may not be in line with their own beliefs. In short, it demonstrates that they are open and capable of growth.

Books are also the fastest and cheapest way to change your life. I have little patience for people who can’t solve their own problems when there are literal libraries filled with free resources to address your exact issue.

This year’s roundup of books is very much focused on troubleshooting existence. From breathing to protein to getting what you want from others, here are the 10 books I read that will make for a happier life.

Landbridge: A Life in Fragments by Y-Dang Troeung

This is the best, most impactful book I read all year. It earned rare display status in my living room, and I tear up just looking at it. It’s also written by a friend who died a year ago this week, so I’m feeling especially tender.

Though you can get creative and get this book in the US by following my link, it’s currently only available in Canada. The US release date is set for later this year.

“In 1980, Y-Dang Troeung and her family were among the last of the 60,000 refugees from Cambodia that then-Prime Minister Pierre Trudeau pledged to relocate to Canada. As the final arrivals, their landing was widely documented in newspapers, with photographs of the PM shaking Y-Dang’s father’s hand, reaching out to pat baby Y-Dang’s head. Forty years later, in her brilliant, astonishing book, Y-Dang returns to this moment, and to many others before and after, to explore the tension between that public narrative of happy ‘arrival,’ and the multiple, often hidden truths of what happened to the people in her family.

In precise, beautiful prose accompanied by moving black-and-white visuals, Y-Dang weaves back and forth in time to tell stories about her parents and two brothers who lived through the Cambodian genocide, about the lives of her grandparents and extended family, about her own childhood in the refugee camps and in rural Ontario, and eventually about her young son’s illness and her own diagnosis with a terminal disease. Through it all, Y-Dang looks with bracing clarity at refugee existence, refusal of gratitude, becoming a scholar, and love.”

Breath: The New Science of a Lost Art by James Nestor

In the realm of books that will solve most of your problems, Breath is #1 on the list. Told with a journalistic flair that keeps you reading, Breath explores the most basic, common thing humans do—breathing—and explains exactly why you’re doing it wrong, how it’s creating your physical problems, and how to fix it with a quick trip to the drug store.

The Medium is the Massage by Marshall McLuhan

It’s been six months since I stopped consuming any news or current events, and I cannot overemphasize how much this choice has positively affected my life. McLuhan’s book is a meta, visual explanation of why this occured, showing how we are unconsciously influenced by media through brilliant illustration.

And lest you think this book falls into the camp of “dangerous alternative media,” know that it was first published in 1967, establishing it as one of the rare works that stands the test of time.

Forever Strong: A New Science Based Strategy for Aging Well by Dr. Gabrielle Lyon

Much of my year has been focused on understanding how nutrition affects mental and physical performance. I’ve ditched dozens of foods I thought were helping but turned out to be hurting—oats, kale, and seed oils to name a few—and am focusing on a more primal, stripped back diet that leans more into red meat.

An easy read with a focus on unraveling the false narrative surrounding meat, Lyon touches on the history of our bogus food pyramid, why so many people are physcially weak and overweight, and how more muscle means better health and longevity.

Born to Run: A Hidden Tribe, Superathletes, and the Greatest Race the World Has Never Seen by Christopher McDougall

I picked this book off a friend’s shelf when I was too jetlagged to function, and it changed my entire perspective on what my body was capable of doing.

In less than three months, I went from someone who hated running and thought I wasn’t “built” for it to someone who is excited to spend an hour in the woods, running six miles with 2000 feet of elevation.

Plus, it’s a damn good story that will speak to anyone with any inclination towards physical activity.

Walking in Wonder: Eternal Wisdon for a Modern World by John O’Donohue

I like to read philosophy or poetry before bed, and John O’Donohue is the perfect lullaby.

“Widley recognized as one of the most charismatic and inspirational enduring voices on the subjects of spirituality and Celtic mysticism, these timeless exchanges span a number of years and explore themes such as imagination, landscape, the medieval mystic Meister Eckhart, aging, and death. Presented in O’Donohue’s inimitable lyrical style, and filled with rich insights that will feed the ‘unprecedented spiritual hunger’ he observed in modern society, Walking in Wonder is a welcome tribute to a much-loved author whose work still touches the lives of millions around the world.”

The Myth of Normal: Trauma, Illness, and Healing in a Toxic Culture by Gabor Mate

Read this book. Just do it. Listen to it on audiobook if that’s what you need to do. Make it the only book you read if you only choose one.

“Over four decades of clinical experience, Maté has come to recognize the prevailing understanding of “normal” as false, neglecting the roles that trauma and stress, and the pressures of modern-day living, exert on our bodies and our minds at the expense of good health. For all our expertise and technological sophistication, Western medicine often fails to treat the whole person, ignoring how today’s culture stresses the body, burdens the immune system, and undermines emotional balance. Now Maté brings his perspective to the great untangling of common myths about what makes us sick, connects the dots between the maladies of individuals and the declining soundness of society—and offers a compassionate guide for health and healing.”

Crazy Like Us: The Globalization of the American Psyche by Ethan Watters

If you’re a regular reader of HIAS, you’ll recognize this book from several of this year’s issues. This book should be required reading for anyone in the mental health field, becuase it’s going to force you to re-evaluate what you think mental illness is.

A Walk in the Physical: Understanding the Human Experience Within the Larger Spiritual Context by Christian Sundberg

By far the most out-there reccomendation on this list, A Walk in the Physical is the account of a man who was born with the spiritual veil “half open.” He remembers life before life, and attempts to explain what happens to souls before we come into human form—and after we leave through death.

Though the writing isn’t going to win any awards, it’s worth reading simply for the premise. Whether you belive what he’s saying or not, its sure to make you think.

How to Win Friends and Influence People by Dale Carnegie

“Why are you reading Dale Carnegie? He was old when I was your age.”

This is what said to me when she saw this book on my coffee table, indicating just low long this book has been around. Classics are classics for good reason, though, and there are plenty of nuggets in Carnegie’s book that are still relevant today.

The trick I use the most: Using people’s name to get what I want.

When you’re interacting with people, whether it’s a cashier or someone you know personally, play around with saying their name when making a request or giving a complement. We are conditioned to respond to our name, and assuming the tone is in kind, you’ll be shocked at how much easier it is to get people to help or respond to you.

On October 9, 2023, the United Nations and World Health Organization jointly released a 184 page report addressing the massive human rights violations that occur in mental health “care” all over the world—including the United States and Canada.

After looking through the document, I’m at a loss for words. I’ve spent years speaking alongside other titans, all of us trying to blow the whistle on the corrupt, evidence-less, biomedical model of mental illness that leads to detrimental over prescription, forced institutionalization, and “treatment” without consent. This work has opened all of us up to a special portal of hell, where defamation, academic mobbing, death threats, and the constant risk of getting sued is always on the mind.

(Never have I been so happy to not be associated with an institution. I have a lot more latitute to speak freely when I am not at risk of losing a license or my job with a University.)

And yet, this is a 184 page report effectively says we were right all along. Addressing the harm of the biomedical model, it proposes new legal objectives and a clear mandate for mental health systems to adopt a rights-based approach as opposed to a containment-based approach. It also admits:

Mental health and well-being are strongly associated with social, economic, and physical environments, as well as poverty, violence, and discrimination. However, most mental health systems focus on diagnosis, medication, and symptom reduction, neglecting the social determinants that affect people’s mental health.

Imagine that! Living under constant threat, whether familial or political, isn’t the way to health and wellness. Whoda thunk?

Furthermore, the document goes into considerable detail on informed consent in psychiatric care, which is generally nonexistent in current practice. This manifests in a variety of ways, from involuntary psychiatric holds to general practioners handing out antidepressants after five minute appointments to psychiatrists refusing to support their patients in tapering from psychiatric drugs.

The document says, specifically:

Countries should adopt a higher standard for the free and informed consent to psychotropic drugs given their potential risks of harm in the short and long term. . . . Legislation can require medical staff to inform service users about their right to discontinue treatment and to receive support in this. Support should be provided to help people safely withdraw from treatment with drugs.

More than anything, though, I am shocked and impressed that the WHO and UN admitted the following:

An additional concern is the explicit use of a reductionist Western biomedical model in mental health law, which works to the detriment of other holistic, person-centred and human rights-based approaches and strategies for understanding and addressing distress, trauma, and unusual perceptions or beliefs (2, 86).

Reductionist Western biomedical model! My god, if this was a snark Substack, that statement would come with a dramatic reaction gif.

Actually, fuck it. My filters are gone.

It’ll be interesting to see how—and if—this document has any real impact on legistlation and operating procedure. I doubt there will be a rush to change any laws any time soon, at least in the United States, as long as Big Pharma continues to hold their lobbying power.

However, one major change is that for those branded with scarlet letters ranging from “dangerous” to “anti-medicine” to “anti-science” we can now point to this report for hard-to-argue-with evidence and support. As I’ve said all along, change on this front is not going to come from the top down. It’s going to start with each individual taking control of their own care, and finally, there’s a document to support it.

Download the report.

When we left off in the early 20th century in the last issue of HIAS, A Brief History of Psychiatric Diagnosis, Part I, a few themes had emerged:

Keep these themes in mind as we explore the origin story of the Diagnostic Statistical Manual of Mental Disorders.

Though it was Richard von Krafft-Ebing and Josef Adolf Hirschl who propagated the biological model of mental illness thanks to their work with syphilis, it is German psychiatrist Emil Kraepelin who is most responsible for the genesis of the DSM and its stronghold over our modern psychiatric system.

Born in 1856, Kraepelin’s work began to attract attention in 1893. Kraepelin ran a clinic at the University of Dorpat and determined that because patients often showed similar symptom patterns, he could use those patterns to classify psychiatric disorders. For example, he observed that manic-depressive insanity did not deteriorate into dementia praecox (what we now call “schizophrenia.”) Dementia praecox, on the other hand, appeared in adolescence and progressed to dementia and institutionalization. One did not morph into another, indicating to Kraepelin that despite some similar symptoms, they were two separate ailments.

Kraepelin took this theory and applied it to all expressions of psychiatric distress that existed at the time. He coined the term “depression”, distinguishing it from the melancholia umbrella that had described human suffering for centuries, and separated the “paranoid thinking of schizophrenia” from “paranoia.” He was fixated on objectivity and measurability, eschewing notions of stress, environment, personality, and their potential impact on mental illness.

He was also a rampant eugenicist. A letter to the editor published in the American Journal of Psychiatry put it bluntly:

In a 1919 paper titled “Psychiatric Observations on Contemporary Issues,” Kraepelin proclaimed that “dreamers, poets, swindlers and Jews” possess “distinctly hysterical traits” and fall outside the bounds of normality, adding that Jews exhibit “frequent psychopathic disposition.”

Kraepelin died in 1926, but his belief that “reasonable policies of racial hygiene” were the solution to Germany’s “degeneration” problem deeply influenced Nazi ideology and the rise of the Third Reich.

While an obvious display of eugenics was playing out in Europe during the first half of the 20th century, the American Psychiatric Association (APA) was busy with a more inconspicuous systemization. In 1913, the APA set up a statistics committee that eventually took responsibility for classifying psychiatric diseases. Combining American observation with Kraepelin’s work, these publications ruled American psychiatry through World War II.

We need to pause for a moment in order to highlight an oft-ignored aspect of this early American classification. It must be noted that as reported by the American Psychiatric Association itself, “Between 1892 and 1947, 31 presidents of APA acted in leadership positions in eugenics organizations, during their time as president, but also in the years surrounding their presidencies.”

Let that sink in for a minute. During the time in which the foundation for all modern psychiatric diagnostic strategies was built, the people in charge of creating that system held the same beliefs as Hitler. Literally, your kid’s ADHD diagnosis or your bipolar diagnosis is rooted in the same categorization and rationale that led the Nazis to exterminate six million Jews.

Combine this with the Social Darwinist movement pervading white-collar industries at the time, and it’s no surprise that the intellectual elite worked to sort folks into acceptable and flawed stock. And don’t think this was an act of good intentions gone awry. Even the modern IQ test that we still use today, which was developed around the same time, is rooted in eugenics. Developed by noted American eugenicist Henry H. Goddard, the IQ test ranked those he considered “feebleminded” into three categories of perceived incompetence: pre-verbal “idiots” illiterate “imbeciles,” and high-functioning “morons.” According to a law review of the landmark murder trail Atkins vs. Virginia, which hinged on the definition of mental retardation, Goddard “found morons wherever he looked: criminals, alcoholics, prostitutes, and anyone ‘incapable of adapting themselves to their environment and living up to the conventions of society or acting sensibly.’”

But by 1948, though the foundation for systemization was already laid, German eugenic sentiments weren’t exactly popular among the collective. Thus, the APA asked its Committee on Statistics to rewrite the diagnostic system. A rebranding, if you will.

Spearheaded by George Raines, the first edition of the Diagnostic Statistical Manual of Mental Disorders pulled away from German language and theories, instead drawing from the en-vogue influences of Sigmund Freud and Swiss psychiatrist Adolf Meyer. Both Freud and Meyer attributed psychological distress to childhood experiences and in Freud’s case, sexual repression. Kraepelin’s symptom-based sorting system still remained, but because of this shift, psychotherapy dominated psychiatric thinking for a short time.

Right around the time the DSM-I was making its way into clinical practice, psychopharmacology was on the rise after the first mood-altering drug, iproniazid, was accidentally discovered in a tuberculosis ward in 1952. Iproniazid induced euphoria in terminal tuberculosis patients and phenomena so profound, the drug was given to 400,000 depressed people to see if it would have the same effect. It did, but it also caused the blood vessels to constrict to dangerous levels, and administration of the drug was stopped. However, its brief existence brought the chemical imbalance theory of mental illness back to the forefront, and the DSM-II was written with this in mind.

It is at this point that the “pill for every ill” strategy leaves psychiatric wards and enters the homes of everyday folks, in part due to the introduction of tranquilizers and benzodiazepines aimed at women in the early 1960s.

In the early 1970s, after the US/UK Diagnostic Project determined that American psychiatrists and British psychiatrists operated by wildly different criteria for diagnosing schizophrenia (a not-so-surprising twist given that there wasn’t and still isn’t any medical test for schizophrenia or any other mental illness), American psychiatry determined it needed to tighten up its diagnostic strategy.

Robert Spitzer, a biometrician at Columbia University, was assigned the task. It is Spitzer who came up with the checklist, in that in order to meet the criteria for a certain mental illness, the patient had to experience X symptoms out of a list of Y.

The DSM-III also introduced bipolar disorder, borrowing the term from yet another set of World War II-era German psychiatrists, Karl Kleist and his student Karl Leonhard. We all know where this leads. According to Edward Shorter, PhD., “The term went on to become among the most popular diagnoses in psychiatry, as well as the foundation of pharmaceutical fortunes selling ‘mood stabilizers.’”

The DSM-III also added attention deficit disorder to the lexicon, as well as post-traumatic stress disorder and a variety of anxiety disorders.

Shorter continues, “What psychopharmacology had begun, DSM-III finished off; the [psycho]analysts were shown the exit sign from the field, or at least from its commanding heights…the DSM-III began a rapprochement between psychiatry and the rest of medicine.”

Since the publication of the DSM-III in 1980, the “bible” of psychiatric diagnosis has been revised three times, with the DSM-V appearing in 2013. From a clinical level, little has changed in the world of diagnoses since the DSM-III appeared. Patients are still judged by a checklist of diagnostic criteria, psychotherapy and root cause are generally ignored, and no test, scan, or lab exists to confirm or refute a biological or chemical cause for mental illness.

One thing, though, is noticeably different. The size of the Diagnostic Statistical Manual of Mental Disorders has swelled with each edition.

The DSM-III registers at 494 pages and weighs 1.9 pounds.

The DSM-IV is 886 pages and 3.4 pounds.

The updated DSM-V, published in 2022, is 1050 pages and weighs 4.6 pounds.

He who knows syphilis knows medicine.

—William Osler, co-founding physician of Johns Hopkins Hospital

In 1885, the Boston Medical and Surgical Journal made an observation: mental asylums in the United States were full. The journal noted that the number of patients had risen dramatically, with people wandering the halls of asylums with a jerky gait, grandiose illusions, and dementia—a collection of symptoms deemed “general paralysis of the insane.”

On the rise, too, was syphilis. In its late stages, syphilis also creates a jerky gait, grandiose illusions, and dementia. In 1885, it was unclear whether the rise in the insane was due to pathological disease or other influences. But in 1897, a causal link between these symptoms and syphilis was found thanks to German psychiatrists Richard von Krafft-Ebing and Josef Adolf Hirschl.

Krafft-Ebing and Hirschl knew that syphilis could only be contracted once, so they created an experiment where they injected the pus from sores of syphilictics into people suffering from general paralysis of the insane. If the patient became infected, they could say with certainty that the patient had not had syphilis before. However, none of the subjects became infected with the disease, leading Krafft-Ebing and Hirschil to conclude that not only had all of their patients’ been previously infected by syphilis, but that it was a disease that caused their psychiatric symptoms.

Thus, the biological theory of mental illness was born. The connection between the biological nature of syphilis and the undesirable psychological side effects of that illness led researchers to assume that all expressions of mental illness boiled down to a biological malfunction. Given the first neurotransmitter wasn’t discovered until 1921, and more robust science on the matter didn’t appear until the mid 1950s, neurologists at the turn of the century instead focused on what could be observed in autopsies. However, little progress was made. Common psychological ailments of the time, like hysteria and shell shock, left no visible sign of brain tissue damage. This lack of biological evidence bolstered the theories of Sigmund Freud, the father of modern psychology, to say: “The case histories I write should read like short stories and that, as one might say, they lack the serious stamp of science.”

The link between syphilis and mental distress came at a time when a concept called Social Darwinism was hitting its stride. Rooted in Charles Darwin’s theories—though he himself was not directly connected to the movement—Social Darwinists believed that human groups were subject to the same evolutionary principles as plants and animals. Natural selection and survival of the fittest could be applied to sociology, economics, and politics because, in their view, sociocultural ideals were inherently biological. Said another way, it was biology that determined if you were white, male, and physically fit, so therefore, natural selection should be applied. Practically, this meant that Social Darwinists believed the strong should see their wealth and power increase, while the weak should see their wealth and power decrease.

The connection between Social Darwinism and the rise of the global eugenics movement of the late 19th century and the first half of the 20th century is obvious: a group of intellectual white men decided the human race was “de-evolving,” and wielded their power and influence to reverse this perceived course by professing who should and should not bear children. This influence stretched into all white-collar industries, from major businessmen like the Carnegie’s and Rockefeller’s to legal theorists, academics, criminologists, and of course, psychiatrists.

The science—although “science” is a loose term given not a shred of evidence existed then or now to back up the theory—became so pervasive, that by 1914, 44 American colleges had introduced eugenics into their curriculum. Rooted in the language of protecting the average citizen from those who threaten the fabric of society thanks to inferior genes and beliefs (note the connection between the language being used at this time and the language surrounding both sides of modern American political movements), Social Darwinists pushed the idea that the species could not evolve if people of good stock mingled or procreated with undesirables. The undesirables, as you’ll remember from high school World War II history lessons, included everyone from Jews to Blacks to the “feeble-minded” and physically disabled.

As Dr. Boonie Burstow, Canadian feminist professor and psychotherapist wrote of the Social Darwinists a few months before her death in early 2020, “While they saw themselves as progressive and as following the dictates of modern science, what they were wrapping themselves in was a combination of hatred and pseudo-science for there was not a shred of credible evidence supporting their position.”

Again, note the connection between Burstow’s commentary on Social Darwinists of the early 20th century and the mental illness propaganda being pushed into the zeitgeist today.

It is at this time in history when the open practice of eugenics simultaneously becomes both obvious and insidious. In 1920, German psychiatrist and eugenicist Alfred Eric Koch and German jurist Karl Binding penned Die Friegabe der lernichtung Lebensunwerten Lebens, which translates to “Permitting the Destruction of Life Unworthy of Life.” This work directly led to the German T4 program, which allowed for the killing of disabled patients in institutions under the guise of mercy. In 1939, Hitler secretly signed an authorization protecting physicians and administration from any prosecution associated with the program. It was also this program that would develop the gassing chamber used throughout World War II.

To help identify who “qualified” for the T4 program, planners developed questionnaires that were distributed to patients in hospitals, old folks homes, and institutions. Worded and formatted in a way that appeared like a simple census to the average citizen, these forms were actually designed to parse out ancestry not of German blood, those suffering from schizophrenia, epilepsy, dementia, encephalitis, and other chronic psychiatric or neurological disorders, criminals, and those who had previously been institutionalized.

A group of prestigious physicians evaluated the forms and identified those deemed undesirable. After their identification, they were coerced from their institution and transported to their death in a gassing chamber. The families of the victims received an urn and death certificate noting a fictitious cause of death.

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In the next installment of A Brief History of Psychiatric Diagnosis, we’ll look at how the eugenics movement influenced the bible of all psychiatric diagnosis, the Diagnostic and Statistical Manual of Mental Disorders (DSM).

During my sophomore year at Middlebury College, I took notoriously tricky course called Introduction to Modern Logic. An early requirement for philosophy majors (one of the many declarative detours I flirted with before landing on the equally useless History degree), it focused on good reasoning and the technical breakdown of arguments.

A basic example:

If Bellaroo is napping on her dog bed, then Bellaroo is not taking a walk.

Bellaroo is napping on her dog bed.

Therefore, Bellaroo is not taking a walk.

The statement is true in all circumstances, regardless of time, interpretation, or the laws of physics. If Bellaroo is napping on her bed, she is irrefutably not taking a walk.

The point of this course is to help students identify patterns of good reasoning and patterns of bad reasoning, so they have a better idea of what to follow and what to avoid. The tricky part occurs when a statement seems true at first glance, but breaks down when logic is applied. These are called logical fallacies, and they are everywhere.

A few examples:

The Appeal to Ignorance, where we assert a claim because no one can prove otherwise.

People have been praying to God for years. No one can prove He doesn’t exist. Therefore, He exists.

The Bandwagon, where we assume something to be true or good just because many others believe it to be true or good.

Everyone at the gym is wearing Lululemon. I need to buy their yoga pants.

The Red Herring, were we use irrelevant information to distract from an argument.

There are starving children in Africa. Eat your broccoli.

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Psychiatry, more than any other branch of medicine, is saturated with logical fallacies. Hell, we can apply all three of the above examples to cultural rationale within the world of psychiatry and mental health:

The most pervasive logical fallacy in psychiatry and mental health diagnoses, though, is circular reasoning, which is an argument that uses the same statement as both the premise and the conclusion.

The reason why circular reasoning is so pervasive in psychiatry compared to other specialties is because psychiatry doesn’t have any form of objective boundaries. The rest of medicine, generally, agrees on parameters that define a pathological disease. Diabetes in the United States is only diagnosed as diabetes when two fasting A1C blood sugar tests read 6.5% or higher. Doctors—and even different countries—debate 6.5% as the cutoff, but all agree that at a certain point, high blood sugar levels indicate disease.

But psychiatric criteria cannot explain behaviors or experiences through any means beyond subjective opinion. Furthermore, as we’ve been exploring throughout the last few issues, these subjective opinions are rooted in norms and meaning. They can’t be measured independently, and they are not necessarily true across time and culture.

And yet, the flywheel of circular reasoning continues to spin, flinging the world of mental and emotional health further away from the solution. As British child psychiatrist Sammy Tammi said in his open letter on the diagnostic model of psychiatry to the Society of Humanistic Psychology, “The result of this basic [logic] error is that medical scientific knowledge in the area of mental health is at a standstill. No chemical imbalances, consistent neurological differences, genetic abnormalities or markers found. None. Billions of dollars of wasted money on wasted biological research that leads nowhere…higher levels of reported stress and anxiety, higher numbers of people disabled due to a mental health condition and rates of significant improvement from those attending mainstream services hovering at around a quarter to a third of those they see. These are not the outcomes you would expect to see from an effective model of clinical care.”

“When humans do not assume they have rather complete control of their experience, they do not so deeply fear those who have appeared to have lost it.”

—Juli McGruder, anthropologist

As of late, I’ve been learning about the different expressions of perceived mental illness around the world. I use “perceived” in this context because the more I learn, the more I understand that symptoms of mental/emotional distress are tied to cultural expectations. (See the TikTok tics from issue 105.) Said another way, the lifecycle of mental illness is influenced by the macro and micro-level beliefs that surround it. What’s considered crazy in one culture is accepted in another.

On a macro level, the prevalence and intensity of schizophrenia vary from place to place. Men living in urban areas of Sweden, for example, are at a 68% higher risk of being admitted for psychosis than those who live in the countryside. This is also true for urban settings in the United States and Europe, and it remains constant even when migration, drug use, and poverty are taken out of the equation.

Furthermore, a 25 year study conducted by the World Health Organization that began in the 1960s found that people diagnosed with schizophrenia in developing countries have better outcomes, longer periods of remission, and higher levels of social functioning than those in industrialized nations. Known as the International Pilot Study of Schizophrenia, the data showed that over time, 40% of schizophrenics in countries like the United States, Denmark, and Taiwan were considered “severely impaired” compared to 24% of people in countries like India, Nigeria, and Columbia.

Of course, these findings ignited a hot debate because the results are counterintuitive. You’d think all the money, research, and resources would lead to better outcomes. But alas, the data showed the opposite to be true.

(Side note, half a century later, our use of psychotropic medicine continues to reflect what we knew in the 1960s and 1970s. Are poor nations tragically underserved by psychiatry? Or have they avoided the crosshairs?)

This debate is the heart of cross-cultural psychiatry research. While it’s interesting in its own right and the conclusions are, to me, dead obvious, I find the micro influences to be even more interesting. It’s not just about the culture we live in. But the roof we live under.

Expressed emotion (EE) is a term used to describe the way that family members and caregivers interact with a person. High EE is characterized by critical, hostile, and emotionally overinvolved behaviors. Low EE is characterized by warm, supportive, and accepting behaviors. While expressed emotion is not the cause of distress, it can influence the course and outcome in an individual.

We all know that when our actions are met with criticism or hostility, we don’t fare as well. But emotional over-involvement requires more explanation.

Emotional over-involvment is characterized as a range of dramatic behaviors ranging from self-sacrifice, extreme devotion, overprotectiveness, or intrusiveness over a person’s life. Control, essentially.

Ethan Watters uses an example in his book, Crazy Like Us, that describes a mother who was so emotionally over involved with her son’s schizophrenia that she “dropped all other interests from her life. Her sole activity, she reported, was to take care of him and protect him, ‘like a pearl of a diamond.’ This same mother said that she often became so distraught over her son’s plight that she considered committing suicide by throwing herself down the family staircase.”

In addition to raising stress levels in the sufferer—which in this case, could trigger schizophrenic episodes—this maligned strategy is a constant reminder to the person suffering that those around him perceive him to be ill, which in turn, reinforces the idea that something is wrong.

Watters gives a contrasting example of a family in Zanzibar with a schizophrenic daughter, Kimwana, who overdosed her medication and nearly died. Juli McGruder, an anthropologist who witnessed the scene said, “There was no noisy woe-is-me talk or dramatic wringing of hands. [The family] seemed to take it in stride like everything else…When I asked what I could do, [the mother] told me I could take a carton of milk to Kimwana in the hospital.”

The ability for the family unit to keep calm and carry on benefitted Kimwana. The family’s perspective, in part because of Zanzibarian beliefs include spiritual possession, allowed everyone to embrace the idea that difficulties—and even voices in the head—are a natural part of life. Therefore, disruptive behavior as a result of these difficulties was more understandable and forgivable. Kimwana wasn’t viewed as other, or as someone to be feared. She was viewed as a strong expression of what we all have inside of us. This kept her within the social group.

Anglo-Americans have the highest level of expressed emotion compared to different groups around the world. Given that we no longer let our kids have sleepovers, have unsupervised play, or breathe without parental supervision, this shouldn’t be surprising. According to researcher Jill Hooley, Anglo-Americans have a strong “locus of control,” which means they believe a person can be master of their own fate and control their own issues through force of will. The critical, hostile, and emotionally over involved actions stemming from this locus of control aren’t necessarily cruel in intent, but are instead an expression of assumed (and flawed) human nature.

Cultures with more fatalistic or spiritual values place less focus and/or blame on those with mental and emotional distress. Conversely, in cultures that value personal accountability and individualism, highly emotionally involved relatives are actually more hopeful about the disease because they are convinced recovery is a matter of will—both on their part and the part of the sufferer.

But as they say in football (soccer), “It’s the hope that kills you.”

Watters says, “One typical father described his reaction to the schizophrenic break of his son: ‘I went to the library and began reading books about mental illness…I thought: “No, I’m going to fix this.” That is your first instinct as a parent. You’re going to fix it. I thought, “I can get him help. I can get him cured.”…That intense focus, even when it springs from a hopeful engagement of the problem, might be the very thing that exacerbates the illness.”

Furthermore, our obsession with the biomedical model of mental illness only exacerbates emotional over involvement. Take the following Euro-American norms:

By applying these norms to an individual, we separate them from the group by labeling them as Other, all while promoting the idea that recovery is never really possible. How could it be, if mental illness is nothing more than a stroke of bad luck and questionable genetics?

In 1997, Sheila Mehta of Auburn University got curious about whether or not the “brain disease” narrative of mental illness actually reduced stigma, as promised.

In her experiment, she paired up people for what test subjects thought was a simple learning experiment. Unbeknownst to the test subjects in the study, their partners were actors and were instructed to inform the test subjects during the get-to-know-you phase that they suffered from mental illness.

The actor told the test subject that the distress occurred because of the “things that happened to me when I was a kid or that they had “a disease just like any other, which affected my biochemistry.”

In the experiment, the test subject was assigned to teach the actor a pattern of button presses. When the actor got the pattern wrong, the test subject was told to give the actor a “barely discernible” to “somewhat painful” electric shock.

Test subjects who believed their partner had a “disease like any other” increased the severity of shocks at a faster rate than those paired with the actor whose issues were caused by childhood events.

Mehta said, “The results of the study suggest that we may actually treat people more harshly when their problem is described in disease terms. Viewing those with mental disorders as diseased sets them apart and may lead to our perceiving them as physically distinct. Biochemical aberrations make them almost a different species.“

And what is our instinct when we encounter Other? Critical, hostile, and emotionally over-involved behaviors.

So it goes.

As of late, I’ve become fascinated with the idea that mental illness is contagious.

The fascination started with a New York Times article about a wave of thousands of female and gender-nonbinary teens who developed Tourette’s-like tics during the pandemic—because of TikTok.

Arriving in the zeitgeist when people were forced to stay home, TikTok exploded during the pandemic. Videos of people claiming to have Tourettes multiplied on the platform, and because TikTok’s algorithm is built on showing users a wide variety of content—regardless of the user’s preferred interests—Tourette’s videos began popping up on people’s feeds. As of this writing, #Tourettes on TikTok has 8.7 billion views.

Like mental illness, there aren’t any scans or biological markers to diagnose or identify Tourettes. However, Tourettes is categorized as a movement and neurological disorder marked by uncontrolled physical or verbal tics, not a mental illness. It typically presents in males and first appears in childhood, with waxing and waning symptoms.

For the girls with “TikTok Tics,” however, the Tourettes-like symptoms arrived suddenly, with a wave of new cases popping up all over the world. Notably, though, when life began to regain some normalcy and the stress of the pandemic waned, the wave of TikTok Tics receded as well. Thus, it is hypothesized that the unique stress of the pandemic + the unique vulnerability of teenage girls created a tinderbox of stress that manifested in psychologically contagious tics.

This isn’t the first time we’ve observed psychological contagion. This phenomenon repeats itself across both time and cultures. In the Middle Ages, it was believed that humans could be possessed by the spirits of demonic animals, leading a group of nuns at a French convent to meow like cats.

In the 1800s, “hysteria” was a known psychological diagnosis that afflicted women. It included a diverse range of symptoms, including paralysis, stomach pain, amnesia, and day blindness. Hysteria was almost worshiped and certainly fetishized by popular magazines, newspapers, and even public hygiene literature. Much like today, male doctors and scholars of the time filled lecture halls and pontificated on the “quintessential illness of womanhood,” as Ethan Watters said in his book, Crazy Like Us. But by the time the 20th century rolled around, hysteria had largely evaporated from the collective consciousness. Women stopped reporting paralysis and leg weakness, and the symptoms of psychosomatic illness moved on to other expressions.

Even the human reaction to war is tied to the cultural temperature. Medical records of war veterans show that the psychological and even physical effects of war are a reflection of time and place. For British soldiers in the Boer War, the psychological trauma manifested as muscle weakness and joint pain, while American soldiers during the Civil War complained of a weak heartbeat and an aching in the left side of the chest. During World War I, both British and American soldiers experienced “shell shock,” with symptoms that included tremors, ticks, and sensory disturbances. Today, addiction affects veterans of modern war.

As Watters explains, “Although the potential psychic damage of war is indisputable, the process by which that damage becomes an outward symptom is a reflection of the cultural beliefs in a particular time and place.”

Said another way, whether as a PTSD response to war or TikTok, people will unconsciously produce symptoms that reflect the culture’s prevailing cultural diagnosis of the time. The TikTok Tics were not so much a measurable illness, but a subconscious yearning for recognition of internal distress.

The implications of viewing mental illness through this lens, in my opinion, destabilize the entire foundation of psychiatry and psychology. I know, for example, that as a young ballet dancer, the eating disorders I experienced as a teenager were created through community. Anorexia is rampant in ballet not just because thinness is an aesthetic ideal, but because everyone else is doing it. Toss in the death of my father and the emergence of the internet in the early 2000s, and the fixation on thinness festered as a direct result in order to satisfy a need to belong to something while expressing suffering. There wasn’t ever anything wrong with my brain. If anything, it was a sign that my psyche was doing exactly what it should be expected to do in times of great stress. I was simply exhibiting symptoms consistent with the time—no different than if I had started meowing with nuns in the Middle Ages.

For an affliction to be pathological, it seems to me that it should ring true across both time and culture. A cancerous mass viewed under a modern microscope looks the same in Taiwan as it does in the United States. But if mental illness and psychological distress cannot be separated from the culture in which it is experienced, how is a blanket biomedical response ever going to be the answer?

Welcome to Science Corner by Happiness Is A Skill, where I take a few minutes to teach you about the relevant neuroscience of antidepressants and antidepressant withdrawal. No more half assed assumptions without evidentiary support, like the whole chemical imbalance theory of mental illness. The idea that “too little” serotonin causes depression? Or that “too little” dopamine causes ADHD? Obsolete, oversimplified, hogwash conveniently packaged by marketing departments of pharmaceutical companies in order to convince you to “talk to your doctor about Zoloft, because when you know more about what’s wrong, you can help make it right.”

That’s the actual tagline for Zoloft by the way, from 2001. Brilliant, isn’t it? Here’s a very simple explanation for your distress. It has nothing to do with your life or your choices or the bad things that happened to you, but instead has to do with some chemicals in your brain you can’t control. So take this pill and the sun will shine and flowers will bloom and scary thoughts will go away and we’ll all be content. Right? Right? 

If one could die of bullshit overload, I would long be gone.

Instead, let’s talk serotonin transporter (SERT) occupancy, something researchers have actually measured and analyzed in labs.

Let’s start with some background information. The serotonin transporter is a protein in the brain that helps regulate levels of serotonin. When someone takes an antidepressant, the drug binds to the SERT protein and blocks it from transporting serotonin out of the brain, disturbing the brain’s longstanding homeostasis by increasing the amount of serotonin available. When early test subjects reported an elevated mood after taking antidepressants in clinical trials, the assumption was that the increase in serotonin was responsible for this relief, therefore thus forming the basis of the serotonin theory of depression. If more serotonin = happier people, then less serotonin = sad people. And that’s how Prozac was born!

Too bad it was all a pipe dream.

Over time, the brain adapts to the presence of the drug and learns to produce less serotonin on its own. The body is always trying to get back to homeostasis, remember. The pharmaceutical industry spends billions of dollars trying to convince you that they can override hundreds of thousands of years of evolutionary physiology, but the bottom line is the body has to remain in equilibrium to stay alive. If you’re hot, you sweat to cool down. If you’re cold, you shiver to warm up. If either of those systems don’t work like they should, you die.

So let’s say you’ve been on 20mg Prozac (fluoxetine) for ten years and you decide it’s time to come off. Your doctor drops you to 10mg for a few weeks and you tolerate it. Maybe you’re a little emotional and antsy but you can handle it. Your doctor has heard about all this withdrawal stuff so he thinks he’s got it all figured out and tells you not to drop from 10mg to 0, but to instead cut the capsule in half and take 5mg for a week or two. You don’t feel great and wonder if it’s the depression coming back. But you figure you’ll drop to zero and give it a few weeks to know for sure. After all, 5mg is miniscule. Smaller than the smallest dose on the market! They give 5mg of Prozac to six year olds!

You drop to zero and all hell breaks loose—akathisia, huge emotional swings, paranoia, brain fog, gut issues. Back to the doctor you go, because clearly you’re sick and how stupid you were to think that you could operate without the Prozac. So you go back on 20mg. Hell, make it 40mg this time. Clearly, you need it. Your doctor suggests an antipsychotic as well because the paranoia suggests an emergence of Bipolar Disorder. Life, now, is all about managing symptoms.

Where did everyone go wrong? A fundamental misunderstanding of SERT occupancy.

Let’s look at the following graphs, courtesy of researcher Mark Horowitz:

The black curve is the measure of SERT occupancy as determined through brain-imaging techniques called PET scans that allow researchers to see the biological workings of the body. As you can see, at 25mg of fluoxetine, 80% of the serotonin transporters are occupied.

Figure (a) is a representative of the conventional line of thinking for linear tapering of antidepressants. Rather, the idea of lowering dosages by equal, measured steps—5mg, in the case of this graph. The problem is that if you lower the dose of Prozac from 20mg to 5mg—a 75% reduction—SERT occupancy only reduces by 20%. This means that not only are there fewer operating receptors, there is also less serotonin in the brain because the body long ago lowered its production. It is likely that withdrawal occurs at least in part because of this chemical imbalance created through linear tapering. And yes, it is ironic that this time, a true chemical imbalance is responsible.

Due to the hyperbolic nature of SERT occupancy, this dissonance is even more extreme at lower dosages, as seen in Figure (b). At 2.5mg of Prozac—20% of the lowest dose available on the market—SERT occupancy is 40%, just half of what it is at a robust dose of 25mg. This explains why it can be more difficult for people taper as they get closer and closer to zero.

Though SERT occupancy occurs with all antidepressants, the levels of SERT occupancy vary from drug to drug, as shown by this systematic analysis of 10 different psychiatric drugs, done by Anders Sorenson, et al.

The reason why you need to know about this is because it’s likely your prescriber is completely unaware. More understanding of SERT occupancy, as well as more robust research (especially when multiple drugs are involved), would lead to better de-prescribing practices that will likely lessen or eliminate severe withdrawal effects.

In the fictional example I gave above, our now “bipolar” patient needed a much slower taper that followed the hyperbolic curve and was adjusted only once she stabilized from the previous dose reduction. Had she tolerated a 10% reduction—from 10mg to 9mg to 8.1mg to 7.29mg and so on to 0—her brain likely would have had much more time to fire up dormant receptors and naturally ramp up serotonin production, leading to a more gentle, symptom-free re-introduction into a world without SSRIs.

Instead, when she was pulled off too quickly, her system went haywire because neurotransmitters are responsible for regulating the entire body. Instead of recognizing this as withdrawal, both she and her doctor assumed it was mental illness and plunked her back in the system with a shiny new diagnosis. This happens all the time. All. The. Time.

I hope you’ve enjoyed this Science Corner issue of Happiness Is A Skill. Please keep in mind that we are very much in the infancy of antidepressant withdrawal research, and that no single piece of information is the whole answer. But as they say on NBC, the more you know! Ding ding dong!

In the midst of the pandemic, a 35 year old man I’ll call Sav, began shooting hoops in his hometown in Italy. First, he shot from the three point line. Then, he turned around and shot backward, sinking the basketball into the net. A few weeks later, he did it blindfolded. Then backward, blindfolded, and while jumping on a trampoline. 

The trick shot obsession grew to kicking ping pong balls into narrow-mouthed water jugs and launching soccer balls into basketball hoops with a golf club. In less than a year, he amassed millions of followers and cashed fat checks from merch and ad sales. 

Then, in the summer of 2022, Sav went dark. 

As it turns out, the followers, the money, the trick shots—all of it was a result of psychiatric drug withdrawal-induced akathisia, a constant state of tortuous restlessness and burning agitation that Sav described as “dishumane.” Unable to sleep or stop moving, Sav channeled his distress into intricate human tricks.

The circus nature of it all kept him occupied in between months long hospitalizations over 30 sessions of controversial electroconvulsive therapy (ECT). He spoke to every known doctor, expert, and advocate on the subject of withdrawal—including me—in hopes that someone could stop the pain. Nothing helped. Most suggestions just made things worse.

Today, Sav is in the process of ending his life through an assisted suicide organization in Switzerland. 

There is an aphorism in medicine, coined by former Dean of Medicine at Harvard Dr. Charles Sidney Burwell that says, “Half of what we are going to teach you is wrong, and half of it is right. Our problem is that we don’t know which half is which.”

I think about this quote constantly, both in the context of my own health and when people like Sav reach out to me for help. I can’t give medical advice since I’m not a doctor, but I can talk about my experience and share resources. Even when I’m passing along research done by other people, it’s a paralyzing to know how much we don’t know, how much I don’t know. What works for one person causes havoc in another. That’s all well and good if the body is strong enough to recover from all the self experimentation. But in a case like Sav’s, any little change seems to set off a cascade of irreversible negative effects.

So much of medicine, and especially a new field like psychiatric drug withdrawal, is focused on the how, not the why. The why is too expensive, requiring oodles of money and serious research. Sav’s case is the perfect example. He followed the leading theory of tapering off psychiatric drugs—hyperbolic tapering—a strategy that encourages small dose reductions, each one smaller than the one before, over a long period of time. Research shows that generally, this method lessens or eliminates withdrawal symptoms by allowing the brain and body to adjust without getting overwhelmed by the sudden lack of drug presence.

But there is a subset of people like Sav who don’t seem to tolerate this method. Instead, it’s like their body hits a limit with how much of the drug they can process, and these long tapers basically become prolonged poisoning. Sav told his doctors over and over again that he thought the taper was hurting him. He was dismissed and told to stay the course. Not knowing what else to do, he followed their advice. And he’s now going to Switzerland because of it.

I’ve heard similar stories from enough people to know that Sav’s story is not a one off. For these folks, there’s something going on physiologically that’s outside of the norm. My hunch is that it has something to do with the genetic component of their body’s CYP system, a complex bodily function involved in the metabolism of drugs, chemicals, hormones, and neurotransmitters. But until someone designs a study for people in withdrawal that analyzes genetic variants in the CYP system, it’s all just a guess. And I’m sure it’s not that simple. I’d also like to see fMRIs, qEEG, hormone panels, and VO2 max tests for people in withdrawal. Until that actually happens (if it ever happens), people like Sav are going to suffer thanks to well intended but myopic views.

Personally, I don’t know know how to deal with this. I’m heartbroken over Sav. I feel like the community failed him. It’s an impossible position for everyone. What percentage of people are sacrificial lambs on the path to truth and understanding? How do you instill hope in the hopeless? How do you help when sometimes the help is poison?

If there is any silver lining to this story, it is this: Sav told me he does not want to go quietly. He wants the world to know his story. We have a little bit of time. The checks and balances in Switzerland are many, for good reason, and he does not yet have a date.

Of course, I hope that between now and then some miracle shows up and he finds some relief. If not, I have to assume that he is a player in a bigger game. That somehow, his suffering won’t be in vain because it will lead to more awareness and education. He is, after all, a bit of a showman. Every trick shot sunk not just to distract himself, but to prove that nothing is impossible.

I will share his real name when he is ready to fully go public. In the meantime, he has given me permission to share his story. Thank you for reading.