by Jeffrey Dach MD
A Young Woman with Depression and PMS Gets Off SSRI Drugs,and Reclaims Her Life, a Case Report
Thirty Two old Debbie came into my office on November 7, along with her Dad, complaining of severe PMS, painful periods with irregular cycles for which birth control pills had been tried and discontinued because of side effects.
Debbie is so depressed that she spends much of her time alone in her room. She is on two different antidepressants, Zoloft 200 mg/day and Wellbutrin 300 mg/day prescribed by her psychiatrist. She has been unable to sleep for many years without Ambien, a prescription sleep drug. Her Fast Food Diet diet from McDonald’s, Wendy’s and Taco Bell, and lack of exercise has left her overweight. She takes no nutritional supplements. Her physical exam shows dilated pupils, dry skin, and brittle thin nails. Her reflexes, although hyperactive, are delayed (230 msec).
Debbie’s labs showed a low Vitamin B-12 level of 304 (normal above 400), and an extremely low Vitamin D level of 14 (deficiency is below 20). Her thyroid labs were low with a TSH of 4.0 (normal less than 2.5), and a free T3 of 270 (normal 230-420). Her luteal phase progesterone level was low as well.
Dilated Pupils, a common finding on SSRI Drugs.
Deciding to Get OFF the SSRI’s
I explained to Debbie, that her insomnia, dilated pupils and hyperactive reflexes were du e to the SSRI antidepressant drugs which are over-stimulating her nervous system. When I suggested that she taper off the SSRI drugs, she and her dad breathed a sigh of relief, and said “that was the main reason they came to see me, to get off the drugs.”
I suggested that Debbie and her Dad go back to her psychiatrist and ask the doctor to work with them in getting off the drugs by providing a tapering schedule.
Psychiatrist and Patient – The Psychiatrist Drags His Feet
Later, I learned that her psychiatrist was in general agreement, yet was dragging his feet and refused to provide the tapering schedule for Debbie to get off the SSRI drugs. After waiting a few weeks realizing we were just wasting time, I finally went ahead and called into her pharmacy the authorization to reduce her SSRI dosage in half every week until the dosage was small enough to stop altogether. Tapering is required because the SSRI drugs are chemically addictive and can produce withdrawal effects.
5-HTP for Sleep
For sleep during the SSRI tapering period, I recommended 5-HTP capsules which increases serotonin naturally with no side effects.(20,23,24) She was encouraged to stop the prescription sleep drugs (Ambien).
Studies show that 5-HTP has equal efficacy for depression when compared to SSRI antidepressant drugs such as fluoxetine (prozac). (23,24)
I explained to Debbie that low Vitamin B-12, low Vitamin D and low thyroid function could all be possible causes of depression.
John R Lee MD, Pioneered Use of Progesterone
Natural Progesterone for PMS
The PMS and painful periods were treated with natural progesterone capsules, 50 mg twice a day for the last two weeks of her cycle (days 14-28). The night-time progesterone had the added benefit of helping her sleep.
Debbie was started on natural thyroid half grain daily, high quality multivitamin, B12, vitamin D, and iodine supplementation, stopped the fast food, and began going out more for daily activities.
By December 3, Debbie had tapered down to Zoloft 50 mg per day and Wellbutrin 100 mg per day. She says, “I am feeling good in general. I have a lot of energy. I am out of my room more. I am basically in a good mood, and sleeping about 4 hours a night.”
By mid December, Debbie was off the SSRI drugs and off the sleeping pills.
A Dramatic Improvement
By January 28, Dad calls in and says , “Debbie is doing so much better. She has more energy and is sleeping well. The difference is between Night and Day.”
That same day, Debbie calls in and says, “I feel a lot better. My energy is pretty good. I am back to work at my mother-in-law’s business at the sales counter. I am sleeping good at night 6 ½ to 7 hours. My mood is stable, pretty much happy. More normal than before. I’m not snappy, and not in my room as much. I am getting out and doing stuff.”
Regarding her last menstrual cycle, Debbie remarked “This time, no cramps, no PMS, no mood swings. The progesterone capsules are definitely helping, I have never had a period without pain before. It was awesome to have no pain. Now, I can do normal stuff. Before, when I had my menstrual period, I would be in bed for 7 days because of the pain.”
Adverse Side Effects of SSRI drugs
My previous article discussed adverse side effects of SSRI antidepressants, namely akathesia, a form of agitation which drives people to commit suicide, sexual dysfunction (impotence), tremor, involuntary body and facial movements, tardive dyskinesia, and hyperactive reflexes indicating a hyperactive nervous system. The SSRI induced loss of sexual function may be irreversible even after discontinuation of the drug. (1)
In many studies, SSRI efficacy was no better than placebo raising questions about SSRI efficacy. It is astonishing that today, SSRI antidepressants are the standard mainstream medical treatment for PMS (Pre-Menstrual Syndrome). In addition, BCP’s, birth control pills are frequently given as treatment for PMS, irregular periods, or any female complaint for that matter (relating to cycles). Natural, bioidentical Progesterone is a far better and more effective alternative for PMS. Broda Barnes found irregular cycles frequently responded to natural thyroid in spite of “normal” thyroid labs.
SSRI drugs for PMS – The Wrong Way
A Practice Which Should Be Abandoned
SSRI antidepressants may have some justifiable uses as a temporary treatment in the severely depressed. However, the widespread usage of SSRI antidepressants for PMS and Menopause should be abandoned.
Women on SSRI antidepressants for PMS, or menopausal symptoms should be encouraged to taper off the SSRI drugs (under a physician’s supervision). The correct diagnostic workup includes hormone levels, thyroid panel, vitamin D and B12 levels. Treatment with natural bio-identical progesterone, natural thyroid and vitamin supplementation is more effective with fewer side effects than the current mainstream use of SSRI antidepressants or BCP’s (birth control pills).
A Successful Outcome
The case of Debbie Depressed illustrates a successful outcome treating depression and PMS with progesterone, natural thyroid, vitamins D and B12, and by modifying diet and lifestyle. It is very gratifying to see Debbie make such a dramatic recovery after discontinuing the SSRI drugs.
References for Causes of Depression:
Low vitamin B12 levels are associated with depression. (2)(3)(4) (5)
Low Vitamin D levels are associated with depression.(6) (7) (8) (9)
Low thyroid function is also associated with depression. (11) (12)
Lastly, bioidentical progesterone has been widely used as an effective treatment for PMS (Pre-Menstrual Syndrome). (13,14)(18,19)
How to Tapering off Benziodiazepines: Dr Heather Ashton.
Adendum 3/9/15: FDA bans Wellbutrin. A Drug Recall That Should Frighten Us All About The FDA David Maris Contributor Forbes. FDA finds lack of efficacy of high dose generic Wellbutrin XL 300 mg by Teva.
Update Sept 2015: BMJ article: Paxil found no more effective than placebo,Le Noury Joanna, Nardo John M, Healy David, Jureidini Jon, Raven Melissa, Tufanaru Catalin et al. Restoring Study 329: efficacy and harms of paroxetine and imipramine in treatment of major depression in adolescence BMJ 2015; 351 :h4320.
Update 2015: Kirsch, Irving. ” Antidepressants and the placebo effect Kirsch Irving Zeitschrift für Psychologie 2015
Articles With Related Interest:
(1) Adverse side effects of SSRI drugs, Paxil, Prozac and SSRI Induced Suicide by Jeffrey Dach MD http://www.drdach.com/Paxil_Prozac_Suicide.html
Low B12 and Depression
High vitamin B12 level and good treatment outcome may be associated in major depressive disorder Jukka Hintikka , Tommi Tolmunen , Antti Tanskanen and Heimo Viinamäki Department of Psychiatry, Kuopio University Hospital, Kuopio, Finland BMC Psychiatry 2003, 3:17 December 2003
Vitamin B12 Deficiency and Depression in Physically Disabled Older Women: Epidemiologic Evidence From the Women’s Health and Aging Study Brenda W.J.H. Penninx, Ph.D., Jack M. Guralnik, M.D., Ph.D., Luigi Ferrucci, M.D., Ph.D., Linda P. Fried, M.D., Ph.D., Robert H. Allen, M.D., and Sally P. Stabler, M.D. Am J Psychiatry 157:715-721, May 2000
Treatment of depression: time to consider folic acid and vitamin B12, Journal of Psychopharmacology, Vol. 19, No. 1, 59-65 (2005). Alec Coppen
Vitamin B12, Folate, and Homocysteine in Depression: The Rotterdam Study, Am J Psychiatry 159:2099-2101, December 2002. Henning Tiemeier, M.D., et al.
“Hyperhomocysteinemia, vitamin B12 deficiency, and to a lesser extent, folate deficiency were all related to depressive disorders.”
Low Vitamin D and Depression
Major Depression and Vitamin D, By John J. Cannell, MD, The Vitamin D Council.
Vitamin D vs broad spectrum phototherapy in the treatment of seasonal affective disorder. J Nutr Health Aging. 1999;3(1):5-7. Gloth FM 3rd, Alam W, Hollis B. Seasonal Affective Disorder (SAD) is prevalent when vitamin D stores are typically low. Improvement in 25-OH D was significantly associated with improvement in depression scale scores.
Depression and Vitamin D Deficiency: Overlooked Vitamin D Deficiency and Depression: Undetected is Untreated, Dr Charles Parker Blog.
(9) MAJOR DEPRESSION AND VITAMIN D , John J. Cannell, MD March 20, 2004 The Vitamin D Council
Low Thyroid and Depression
Inspiring Stories on Depression that Went Away (and other mental health issues) These are actual stories from real patients whose depression went away using desiccated thyroid on the Stop the Thyroid Madness Blog.
Should thyroid replacement therapy be considered for patients with treatment-refractory depression? J Psychiatry Neurosci. 2002 January; 27(1): 80. by
Russell T. Joffe
Is the thyroid still important in major depression? Russell T. Joffe, J Psychiatry Neurosci. 2006 November; 31(6): 367–368.
Progesterone for PMS:
The PMS Treatment Clinic- the nation’s leading PMS Clinic was established in 1982 and began treatment of Premenstrual Syndrome with natural progesterone therapy according to the method of PMS world authority Katharina Dalton M.D. of London, England. (Sadly, Katharina Dalton passed away on September 17, 2004 at the age of 87.) The Premenstrual Syndrome Treatment Clinic uses bioidentical hormones exclusively in the treatment of premenstrual syndrome and menopause. Since its inception, 35,000 patients from all over the United States and 28 countries have been evaluated and treated.
Interview with Katharina Dalton, MD Progesterone and Related Topics, Dr. Dalton successfully treated PMS, pre-eclampsia, eclampsia and post-partum depression with natural progesterone.
Thyroid for Irregular Menstrual Cycles
Hypothyroidism the Unsuspected Illness, by Broda Barnes MD, An observation by Dr. Barnes is that low thyroid is associated with menstrual irregularities, miscarriages and infertility. Barnes treated thousands of young women with thyroid which restored cycle regularity and fertility. In his day, the medical system resorted to the drastic measure of hysterectomy for uncontrolled menstrual bleeding. Although today’s use of birth control pills to regulate the cycles is admittedly a far better alternative, Barnes found that the simple administration of desiccated thyroid served quite well. Again, Barnes noted that blood testing was usually normal in these cases which respond to thyroid medication.
What is the Normal TSH Level?
American Association of Clinical Endocrinologists, Until recently, physicians accepted the normal TSH range of 0.5 to 5.0 mIU/L. The National Academy of Clinical Biochemistry (NACB guidelines believes that a sustained TSH level above 2.5 mIU/L might not be normal.
The TSH Normal Range: Why is There Still Controversy? Insights from One of the Nation’s Leading Endocrinologists, Dr. Jeffrey Garber said in practice, he doesn’t hesitate to treat a patient who is in the 2.5 to 5.5 TSH range In late 2002, the National Academy of Clinical Biochemistry (NACB issued new guidelines for TSH of 0.4 and 2.5. January 2003, the American Association of Clinical Endocrinologists (AACE), issued their TSH range of 0.3 to 3.0. (Normal range for free T3 is 230-420).
Progesterone for PMS
John R Lee MD web site, pioneered use of natural progesterone.
Dr. Phil Interviews Holly Anderson on Treating PMS with Natural Progesterone
5-HTP for Depression
(20) Meyers, Stephen. “Use of Neurotransmitter Precursors for Treatment of Depression.” Alternative Medicine Review 5.1 (2000): 64-71. Neurotransmitter Precursors for Depression 5HTP Stephen Meyers Alt Med Rev 2000In a 1988 open study of 25 patients, the therapeutic efficacy of 5-HTP was found to be equal to traditional antidepressants.
(21) Kirsch I, Deacon BJ, Huedo-Medina TB, Scoboria A, Moore TJ, Johnson BT. Initial Severity and Antidepressant Benefits: A Meta-Analysis of Data Submitted to the Food and Drug Administration. Hay P, ed. PLoS Medicine. 2008;5(2):e45.
(22) Vitamin D Deficiency Is Associated With Low Mood and Worse Cognitive Performance in Older Adults. Consuelo H. Wilkins, M.D., Yvette I. Sheline, M.D., Catherine M. Roe, Ph.D., Stanley J. Birge, M.D., and John C. Morris, M.D. Am J Geriatr Psychiatry 14:1032-1040, December 2006
24) Asian J Psychiatr. 2013 Feb;6(1):29-34. Comparative study of efficacy of l-5-hydroxytryptophan and fluoxetine in patients presenting with first depressive episode. Jangid P1, Malik P, Singh P, Sharma M, Gulia AK.
Role of l-5-hydroxytryptophan (l-5-HTP) in depression is relatively less studied but the literature has shown its robust role in depression. The present randomized double blind study was undertaken to assess the role of l-5-HTP as an antidepressant and to compare its antidepressant efficacy with fluoxetine in first depressive episode patients of Indian population.
METHODS: A total of 70 patients of first depressive episode, all of whom were diagnosed with ICD-10 criteria, were recruited but only 60 patients completed the study and were randomly divided into two groups, receiving l-5-HTP and fluoxetine, respectively, for a period of 8weeks. All patients were administered Hamilton Rating Scale for Depression (HAM-D) to assess severity of depression at baseline, 2weeks, 4weeks and 8weeks. The efficacy of treatment was assessed by comparing HAM-D scores obtained at these examinations with the baseline examination; final evaluation of both efficacy and tolerance was assessed using the Clinical Global Impression (CGI) scale at the end of study.
RESULTS: Both treatment groups showed significant and nearly equal reduction in HAM-D scores beginning at week two and continuing through week eight. Twenty-two patients (73.33%) in the l-5-HTP group and 24 patients (80%) in the fluoxetine group showed positive response at the end of the study.
CONCLUSION: l-5-HTP has definitely got antidepressant effect in patients of depression. Antidepressant effect was seen within 2weeks of treatment and was apparent in all degrees of depression. The therapeutic efficacy of l-5-HTP was considered as equal to that of fluoxetine.
Jeffrey Dach MD
7450 Griffin Road Suite 190
Davie, Fl 33314
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