SSRIs/SNRIs should never be prescribed without a warning of P.A.N.E.S.
Debate Rounds (5)
To those of who are unfamiliar with medicine, or who simply do not wish to delve too much into research, I will give a brief overview on what this debate is about.
SSRIs and SNRIs are simply abbreviations for certain classes of antidepressants which are very commonly prescribed and taken by millions worldwide. The incidence of PANES, another abbreviation that simply refers to "long lasting neural effects" after discontinuation of the medicine, is why my opponent is concerned with proper counseling.
I will argue in later rounds that there are indeed a variety of situations in which these classes of medications can be prescribed without a warning of PANES, and that the concern my opponent expresses is not warranted to the level that he displays.
I ask of my opponent the following questions:
1. What is the incidence of PANES developing in patients who take their antidepressants in a responsible manner, without abruptly discontinuing it, but rather, titrating the dose downwards?
2. How often and in how much depth do prescribers counsel their patients on their medication?
Thank you to the audience, and to my opponent. As there are five rounds, I will anxiously await the clarification of my opponent's opening statement and his initial argument.
In response to your first question, there are no concrete numbers; mostly mountains of anecdotal evidence that continues to accumulate exponentially. As examples of anecdotal evidence online, you skim through this thread:
It consists of a whopping 436 pages. That is huge, and it's not even a blanket thread concerning all SSRI/SNRI withdrawal; it's focused on one, Escitalopram. It consists largely of posts made by people suffering PANES because of ignorant physicians. If you skim through it, you can find people victimized by PANES even though they titrated by what their doctor's think is a responsible amount. I think the following quote sums up the main reason it is so easy to put down PANES as merely an underlying illness:
"The withdrawal syndrome complicates the evaluation of patients after drug discontinuation since both
patients and physicians often interpret the onset of symptoms as an upsurge of "anxiety" related to incipient
relapse, and resume treatment with the gratifying subsidence of the "anxiety". This may cause both patients
and physicians to overvalue the importance of the medication to the patient"s stability". (1)
In response to your second question:
I don't think there are any studies on this. However, it's common knowledge that SSRIs are typically first-line treatment for any depression or anxiety disorder. This strongly suggests doctors view them as relatively benign in comparison to other medications.
To recap for the audience:
My opponent has essentially constructed a clear story to the audience: A population of individuals suffering from persistent, unending withdrawal effects of a group of medications, which is allegedly the result of a lack of communication between prescriber and patient. From that elucidation, my opponent seeks to promote the notion that SSRIs and SNRIs should never be prescribed without an adequate warning to the patient of these persistent withdrawal effects, due to the inherent danger present in the use of those medications. The problem is that there are several key issues with the story that change the plot drastically.
Now, let us examine my opponent's first source: Drugs.com
My opponent points to "mountains" of anecdotal evidence on drugs.com, and I approach that source with much hesitancy. Why? Because my opponent is not pointing to the actual documentation on the site, but rather to the information on the forums.
My opponent has stated "It consists largely of posts made by people suffering PANES because of ignorant physicians". Realistically speaking, my opponent cannot make that claim. He is only echoing the assumptions of those on the site, a collection of individuals with no medical training, who cannot diagnose themselves, and who are simply feeding off of each other's descriptions of side effects.
A closer examination of this site shows that the individuals are doing a wide variety of things that as a professional pharmacist, I know to be against doctor's warnings. On every page, there is one mention of patient self discontinuation or self tapering, patients trying to turn their medication from solid to liquid form, patients confusing side effects with withdrawal symptoms, patients confusing their own recurrent symptoms with withdrawal symptoms, patients misinterpreting "addiction" with "withdrawal", and a general complete lack of coherency. The vast majority of these patients are NOT suffering from PANES, but from drug interactions between different classes of antidepressants, improper medication use, general side effects of the medications themselves, recurrent symptoms from their discontinuation, as well as mild forms of withdrawal symptoms that are transient and not permanent.
My heart goes out to the individuals who are suffering, but we must keep our minds clear in this particular matter. The individuals on the drugs.com forum are *not* a credible source for the prevalence of PANES.
Now, on to my opponent's second source.
The acronym "PANES" is only really used by one particular author for one particular paper regarding SSRI withdrawal, and it specifically refers only to PERSISTENT, unending symptoms after withdrawal. "SSRI Withdrawal Syndrome" is the general term, which encompasses the persistent as well as the transient symptoms after SSRI discontinuation.
The crux of his argument regarding PANES revolves around this one article that my opponent has provided:
In it, the author produces five cases in which patients have extreme forms of SSRI withdrawal that seem to last for months. I agree, it sounds frightening, but there is something to note: This is not a clinical trial. It is simply a collection of five cases. "PANES" does not actually exist, even the author makes the statement:
"Further case reports and surveillance data are needed to establish the significance or otherwise of what we propose to be persistent adverse neurological effects of SSRIs (PANES)."
The very source my opponent bases his entire argument on, is questioning whether or not PANES actually exists! This article, which is nothing but a collection of five stories written over a DECADE ago, has had no major updates tagged indicating that PANES has truly been discovered. In fact, a google search shows that the only people who talk about PANES, happen to be the same type of people in my opponent's first source: Self-diagnosing forum-dwellers.
Finally, my opponent's third source:
What my opponent does not seem to notice, is that this article is not dealing with PANES! It is dealing with transient, temporary withdrawal symptoms, not persistent ones! I, and the scientific community, am in agreement with this article, which indicates that withdrawal symptoms exist. However, PANES refers specifically to the persistent ones, making this article irrelevant.
To conclude, none of my opponent's first three sources are credible and relevant. I must ask my opponent to resubmit his arguments using credible and relevent sources.
That having been said, I now make my own advance.
The very core of my opponent's argument, is that the patient should be warned of PERSISTENT ADVERSE NEUROLOGICAL EFFECTS on discontinuation of the drug. What is the incidence of these persistent adverse effects?
My own professional training teaches that this is extremely rare, and it would harm many more patients by frightening them out of taking beneficial medication. However, I know this is likely not enough for my opponent or for you, the audience.
This study indicates that the majority of symptoms coming from SSRI withdrawal are "self limiting and reversible".
This review on several studies of SSTI withdrawal concludes that the effects tend to be "short lived and mild", whie offering many ways to prevent and treat the withdrawal symptoms.
There are many studies and reviews indicating that SSRIs have withdrawal symptoms, but that these can be managed effectively and often do not last. In my research, I have only come across some that even start to mention persistent effects and even then, only in passing and indicating that it is quite rare.
My opponent is right in saying that doctors often treat SSRIs as benign because they are considered first line treatment. This is because for the most part, they are. Doctors may not explicitly tell their patients that they can develop persistent withdrawal symptoms, but they often do tell them that they can develop transient ones. Even if they do not, many doctors intend to keep their patients on antidepressents for a significant period of time, in conjunction with therapy and counseling, before they even THINK of taking their patients off the drug.
The only danger is when patients decide that they want to stop the medication "cold turkey" against their doctor's advice.
As of now, I still cannot see why my opponent feels that prescriptions should *never* be issued unless the doctor warns the patient about an extremely rare condition that can only be brought about by deliberate patient misuse of the drug. Perhaps my opponent can enlighten me, and you, the audience, in his next reply?
I thank you.
Allow me to satisfy your desire for incidence rates from a more reputable source with a quote from Dr. David Healy MD:
"These symptoms appear in anything between 20% to 50% of patients taking SSRIs[...] In milder cases problems may clear up after a week or two, but in others symptoms may continue weeks or months after the last dose and for some patients it may not be possible to stop treatment. Specialist help may benefit some patients in this latter group, if only to provide suggestions on antidotes to continuing drug induced problems such as loss of libido." (1)
In the above quote, Dr. Healy was referring to this list of symptoms, which when persistent, or continuing indefinitely, can be described as P.A.N.E.S. (it must be noted that since PANES is a syndrome, and syndromes are merely a collection of symptoms, any similar collection of symptoms to PANES can be appropriately labeled as PANES):
Dr. Healy's words are another way of saying that some patients suffer side effects caused by their medication that are so persistent, the medication can never be discontinued, since the most common method of dealing with withdrawal (titration, or slow reduction in dosage) does not cure the symptoms. Also, he mentions the existence of continuing (persistent) problems like loss of libido. This problem in particular is particularly concerning, because the only help he suggests, even being a medical doctor with much experience on this topic, is: "Specialist help may[...] suggest antidotes to continuing drug induced problems like loss of libido." Note he never mentions the word 'cure' or 'solve;' only 'may.' We are discussing persistent adverse neurological affects that are apparently incurable,presumably unintended by the prescriber, but Con suggests this doesn't warrant a warning in all cases of this medication being prescribed. Con, can you name one instance in which you are sure these P.A.N.E.S. have no chance of occurring?
Just so we're clear on a few points, please let me know if you disagree with any of the following points, and I look forward to your response:
These medications (SSRIs/SNRIs) may cause side effects during use
They may cause withdrawal upon discontinuation, which can be averted under proper care by titrating down properly
These may cause a syndrome similar to withdrawal in effects that is not remedied by titration, and can last months or years
These symptoms described are neurological in nature (which is why the label PANES is appropriate)
The issue being contested is not whether SSRIs can lead to PANES. Through our mutual research, we know that it is generally accepted as fact that SSRIs can lead to *short term symptoms*, and that from that, we can infer that there is the potential for developing persistent symptoms.
**The issue is whether or not a doctor has to be mandated by law to discuss the rare possibility of developing PANES before prescribing any SSRI. **
So, I would ask the audience to exercise caution in reading my opponent's responses. My opponent and I have spent the last few rounds framing the audience's understanding of what PANES is, but from this point on, let us focus on the resolution at hand: *MUST* doctors always warn their patients of PANES before they prescribe SSRIs and SNRIs for any reason?
In my opponent's latest response, he provides a source that seemingly indicates how often a patient develops persistent symptoms, but as the audience can see upon closer examination, the language is vague.
Dr. Healy indicates that the incidence of developing withdrawal symptoms *in general* is "20-50%". He only vaguely indicates that *some* people may develop persistent symptoms. Like I have stated before, my opponent makes a good case on why patients should be warned of *transient* side effects, but not persistent ones.
My opponents asks of me several questions, which I shall now answer.
SSRIs and SNRIs may cause side effects during use, but the crux of this debate is on what my opponent has defined as "PANES" in accordance with his first source, which is a list of symptoms that are caused by the withdrawal of an SSRI, that happen to persist for a much longer duration of time and may be permanent.
Contrary to what my opponent states, "PANES" is not similar to withdrawal. "PANES" is simply persistent withdrawal symptoms, according to the very first source my opponent listed:
Which brings me to my first exception.
1. In order to have PANES, one must stop the medication. If a doctor intends to keep his patient on SSRIs indefinitely, why must there be a warning of PANES?
In patients with severe depression or psychosis, doctors usually keep the patients medicated indefinitely. While there are side effects associated with that use, these are the situations in which problems like suicidal ideation may represent a greater risk to the patient. Emphasizing the possibility of PANES would simply upset the patient or frighten them away from needed treatment.
This brings me to my second point:
2. Patients who have such severe illness that they cannot care for themselves.
SSRIs and SNRIs are frequently used in psychiatric hospitals and psychiatric wards where the patients are simply unable to care for themselves. They are frequently made up of homeless individuals who have no family or friends and who have little remaining mental capability. SSRIs and SNRIs help to restore them to some form of functioning. Most of the time, people are warned about rare side effects so they can exercise judgement and not use the drug. However, for people who are incapable of exercising their own judgement, why would they need to be counseled on such a rare occurrence, especially when they are under constant, vigilant care?
Finally, my third point:
3. Slippery slope
We know that withdrawal symptoms occur with SSRIs, but in none of the sources my opponent and I contributed was there an indication that the persistent withdrawal symptoms were anything but rare anomalies. I asked my opponent for a source showing the incidence of persistent side effects after controlled lowering of the dose, and he has not provided it.
All across the board, there are medications with rare side effects that doctors simply don't have time to discuss. The audience must ask themselves this: Are my opponent's arguments good enough such that they can be applied to ALL similar adverse reactions?
For any class of medications, be they antibiotics, cholesterol medications, blood pressure medications, antidepressants, hormones, antidiabetics, etc. there are always rare side effects that are more severe and better studied than PANES. Doctors simply don't have time to go through all of them, especially when in most cases, they don't have much chance of occurring.
And keep in mind, these are symptoms that occur by being ON the medication. My opponent wants to place this legal mandate for something that may or may not occur only if a patient withdraws from a medication, which is rare in and of itself.
To conclude, my opponent makes many good points, but what he has failed to do so far is explain why SSRIs and SNRIS should NEVER, EVER, EVER be prescribed without a warning of PANES.
The language is vague merely because when describing emotional problems, you can't be certain t you are describing is 100% accurate because emotions are subjective. To be able to describe what emotional problems are like with 100% certainty would require the author of a paper to have experienced it himself. This why the ocean of anecdotal evidence is sufficient support for my argument.
For another source of anecdotal evidence, see http://www.paxilprogress.org... for a forum owned by a certified and practicing nurse who acknowledges the existence of long-term side-effects of SSRI discontinuation, even when performed a doctor's supervision.
PANES actually IS similar to withdrawal. PANES is merely a collection of symptoms; since they are identical to that of withdrawal in every way except their persistence and the fact they may present themselves even before discontinuation, PANES is indeed similar to withdrawal.
I will now refute your 3 points.
1. PANES may occur even without discontinuing the drug.
2. This point is irrelevant; it's an argument against any and all warnings under the described circumstances. If the patient has no say in what treatment they get, what good is warning them of side-effects of the treatment?
3. PANES in the context of SSRIs/SNRIs differs from that of other medications in that it is sometimes resistant to all treatment attempts to alleviate it's effects.
I look forward to your next rebuttal.
In the first round, my opponent introduces the topic and defines PANES in accordance to this source which we shall name Defining Source:
Which states that PANES is defined as "Persistent Adverse Neurological Effects Following SSRI Discontinuation". The article speaks exclusively on withdrawal symptoms.
I respond with more background information for the audience regarding the matter and ask two questions: One of which was never answered in full, and another which was never addressed at all.
My opponent offers Source 2, a forum of people he alleges are "all suffering from PANES" and "victimized by ignorant physicians" when they discontinue or withdraw from their medication.
He then offers Source 3, a study regarding withdrawal and dependence, claiming it shows that doctors misdiagnose PANES upon discontinuation and withdrawal for resurgence of symptoms.
I then completely discredit Source 2 as merely a collection of the unsubstantiated worries of laypersons who, upon close examination of the forum, are doing a variety of things wrong, misdiagnosing themselves, and incorrectly taking medical care into their own hands.
In addition, I discredit my opponent's assumptions about the Defining Source, pointing out that the author himself is unsure whether PANES (persistent neurological symptoms due to withdrawal) is actually significant, and that PANES is actually just "proposed", not proven.
"Further case reports and surveillance data are needed to establish the significance or otherwise of what we propose to be persistent adverse neurological effects of SSRIs (PANES)."
I also discredit Source 3, as I have noticed that the article is not dealing with PANES (persistent withdrawal symptoms), but with SSRI withdrawal syndrome, which is the far more common, transient and self-limiting form of PANES.
My opponent does not address the collapse of any of his sources, and merely offers Source 4, which simply defines a list of neurological symptoms after withdrawal that the source itself says could either be temporary, or in some cases, possibly persistent.
I respond by indicating that I agree with most of these facts, and that it still doesn't contribute any factual evidence that shows that these medications should *NEVER* be prescribed without a mandated warning.
I also raise the following exceptions to the resolution:
1. Since PANES (by definition) only develops during withdrawal, what about doctors who don't intend to discontinue the medication?
2. Should counseling be mandated if a patient is in dire need of medication and in no mental capacity to choose not to take the drug, such as in a psychiatric ward?
3. This list of symptoms being permanent is extremely rare, as evidenced by the lack of studies and sources, and the plethora indicating that its temporary counterpart, SSRI withdrawal syndrome, is far more common. If we mandate counseling for something so rare, wouldn't we be forced to mandate the same for all the other side effects for all other medication? Doctors simply wouldn't have the capacity!
Now, I will respond to my opponent's latest arguments in Round 4:
My opponent submits another source with "anecdotal evidence", however, even in his description he explains why it fails: for the same reason why his initial anecdotal source fails.
"The language is vague merely because when describing emotional problems, you can't be certain t you are describing is 100% accurate because emotions are subjective."
All of these symptoms are blurry and subjective, and these sufferers do not demonstrate that they can accurately diagnose themselves with anything BUT those symptoms. They *cannot* diagnose themselves with PANES, because they cannot accurately determine the difference between withdrawal symptoms and recurrence symptoms, and because the forum is providing a place for people to perpetuate and dwell in their own self-diagnoses.
As of yet, my opponent has contributed no sources that have withstood even mild scrutiny. Now, I will address his attempts to refute my three points. Audience, please note that my opponent's burden is to ensure that there are no exceptions to his resolution and that my burden is to indicate at least one. If my opponent does not satisfactorily disprove all three of my points, this debate is decided. I wish him the best of luck.
FIRST: I have stated that since PANES, as defined, are a collection of withdrawal symptoms that never seem to go away, it makes sense that a doctor who intends for perpetual use should not have to warn about it.
My opponent, for the first time in the debate, attempts to change the definition and say that PANES can occur without withdrawal.
I will point not to my own sources, but to his, indicating that every single source he has put, deals exclusively with discontinuing or withdrawing from medication, and the effects that can have. Even the name of his defining source indicates the following:
"Persistent Adverse Neurological Effects Following SSRI Discontinuation (PANES)."
The acronym PANES encompasses "SSRI Discontinuation" in the very title.
After all of our discussion on whether proper titration for withdrawal can prevent PANES, and about the difference between transient SSRI withdrawal and PANES, my opponent has made this statement without any legitimate basis.
PANES, by definition, is a persistent version of SSRI withdrawal syndrome. I have included this in my own definitions before and my opponent did not seem to have a problem with it until now.
I ask that the audience refuse to accept this new definition as it is not only unsubstantiated, but also too far into the debate. The time for rehashing definitions is over. The time for debating is now.
In that regard, my opponent *must* address my first point.
SECOND: I have noted that there are individuals who do not have the mental capacity or health to make their own medical decisions. Should a doctor need to place this medicine on such a patient, it would not be necessary to warn the patient.
My opponent states that this is irrelevant because "it's an argument against any and all warnings under the described circumstances. If the patient has no say in what treatment they get, what good is warning them of side-effects of the treatment?"
That is correct, and exactly my point. Something need not be specific to be relevant. If you see the news say "All Americans must serve jury duty", would you assume that you need not go serve because it doesn't mention you by name?
This point *is* relevant, audience, and my opponent himself agrees that this is a reason NOT to warn them of the side-effects of treatment. If my opponent concedes this point, then he concedes the debate. An argument against any and all warnings, is still a legitimate argument, because we are dealing with a resolution about a warning.
THIRD: I point out that there are more common and more severe side effects for all other medications outside SSRIs that do not require mandatory warnings to prescribe. My opponent believes that since "sometimes, it is resistant to all treatment", it makes his case special.
However, audience, let me ask tell you, this does not make his case special. In truth, every side effect is "sometimes" resistant to treatment attempts.
In conclusion: As it stands in the debate so far, my opponent has offered no credible sources to his point, and has failed to indicate why SSRIs/SNRIs should *never* be prescribed without a mandated warning. Furthermore, my opponent has attempted to redefine the resolution, and has not refuted my three exceptions.
For my opponent's sake, I hope he addresses these issues in the final round.
Thank you for this debate. I will now present my final arguments.
My opponent attempts to undermine the credibility of my sources by calling them anecdotal; however, because of the subjective nature of PANES, anecdotal evidence is, in fact, the most credible for the purposes of this debate. No amount of scientific literature can conclusively prove that someone is consciously experiencing something; however, it is reasonable to trust someone who tells you they are in pain, that they are, in fact, in pain.
Con also tries to undermine the credibility of http://www.paxilprogress.org..., one of my sources, by calling it a "place for people to perpetuate and dwell in their own self-diagnoses." This is blatantly false. The forum is run by a certified and practicing nurse who encourages an atmosphere of positivity and encouragement. According to the site founder's own words:
"This site will no longer allow victims. It serves no purpose and the only one who loses is the victim. I am here to guide members and offer what I have learned over the last 8 years. I will offer support and advice when it’s asked for. I will hold your hand when you are feeling bad, but will not allow you to fall into the dark hole of "I'll be like this forever". If you choose to argue that you are incapable of recovery, having done nothing to help that recovery, then that will define your outcome. I will not argue that point but I will not allow that negativity to poison the minds of those who truly want to move forward. I will also tell you when you are out of line and not apologize for doing so. Paxilprogress is my home and I expect those who come here to treat it as such.
Paxilprogress is a safe place in the storm to express what one is feeling…and to continue being that safe place it must be a place of hope, not of doom and gloom. When you go to the food store for the first time alone, we will celebrate with you, when you are able to go for that drive, we will celebrate with you, and when you finally post “I’m a success story” we will cheer. That’s what paxilprogress is about. It’s a place to be encouraged, a place to shed a tear, a place to express frustrations, a place to make lifelong friendships through some of the hardest times of our lives.
I want to hear what you tried today…not what you weren’t willing to try. That will make the difference in how we deny being a victim and embrace being who we are, even if that’s not perfect.
Let’s get back to do what we have done so well for so many years."
As evidenced by this quote, this site is clearly not "a place for people to perpetuate and dwell in their own self-diagnoses" as Con tries to claim. People have nothing to gain by exaggerating their symptoms or wallowing in self-pity and self-diagonises.
I will now refute Con's 3 points:
1. Even if PANES is defined as a persistant version of SSRI withdrawal syndrome, the severity and persistancy of the condition still warrants a warning.
2. As I stated in a previous round, this is an argument against the entire principle of warnings themselves, not a an argument against a warning of PANES.
3. Con claims that every side effect of medications is sometimes resistant to treatment attempts. However, PANES is the only incidence where a side effect of medication, which persists after the medication is discontinued, is completely and totally resistant to any form of treatment, including that of reinstating the medication itself.
One must remember that, contrary to what Con seems to believe, subjective emotional experiences cannot be conclusively proven through scientific research, in much the same manner that no studies can conclusively prove exactly what you, the voter, is feeling at this moment in time. However, you can tell us. When a large enough group of people claim to be feeling the same, such as my sources of literally thousands of people, it is reasonable to assume that they are not lying.
Thank you, Con, for this debate. I sincerely hope you (yes, YOU :) vote Pro. I believe that my arguments are the most realistic and convincing.
Kleptin forfeited this round.
1 votes has been placed for this debate.
Vote Placed by Grantmac18 4 years ago
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Reasons for voting decision: Pro refutes his own position several times: "The language is vague merely because when describing emotional problems, you can't be certain t you are describing is 100% accurate because emotions are subjective." "If the patient has no say in what treatment they get, what good is warning them of side-effects of the treatment" But Con FF last round, thus argument cannot be given to him. Pro's sources lacked credibility. Con's arguments were so strong that regardless of his final round FF, I cannot award arguments to Pro.
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