Mental Health Champions: Why & How Dr Mark Horowitz Of Outro Is Helping To Champion Mental Wellness
An Interview With Michelle Tennant Nicholson
The overall improvement in my well-being has been pronounced — my daytime fatigue and serious difficulties with concentration and memory, which plagued me for years while on the medication (and which were diagnosed as various other conditions along the way), have improved and allowed me to be much more productive and sharp than when I was on the drugs.
As a part of our series about Mental Health Champions helping to promote mental wellness, I had the pleasure to interview Mark Horowitz.
Mark Horowitz, MBBS Ph.D. is the scientific co-founder of Outro. He is a Clinical Research Fellow in Psychiatry at the National Health Service (NHS) in England, a trainee psychiatrist, and a world-leading researcher on how to safely stop psychiatric medication (also known as deprescribing) — focused on the principle of gradual, hyperbolic tapering. His firsthand experience with the difficulty of stopping antidepressants inspired him to pursue research and clinical work on the safe deprescribing of psychiatric drugs and that framework led him to co-found Outro.
Thank you so much for doing this with us! Before we dig in, our readers would like to get to know you a bit. Can you tell us a bit about how you grew up?
I grew up in Sydney, Australia. Although for most people that conjures up pictures of sunshine and surfing, growing up in a Jewish household, the grandchild of Eastern Europeans who fled the Nazis in the Second World War, my upbringing was a much more neurotic and introspective affair than that of my easy going, suntanned, sports-obsessed classmates. Much more Kafka and Dostoevsky than Shane Warne, BBQs, and test matches. Combining this with a medical family, and the cultural expectations for immigrant children, I was led the medical field and eventually to psychiatry, with the somewhat cliched motivation to try to fix myself and my family, including taking some of the psychiatric drugs I learned to prescribe.
You are currently leading an initiative that is helping to promote mental wellness. Can you tell us a bit more specifically about what you are trying to address?
Outro addresses the problems that people face when trying to stop antidepressants. Many people are not aware that stopping SSRIs or SNRIs, the most commonly used classes of antidepressants, can cause withdrawal symptoms, which, for some, can be severe and long-lasting and can sometimes be mistaken for a return of people’s underlying condition.
For many years, guidelines have informed doctors that “discontinuation symptoms” (a euphemism for withdrawal symptoms propagated by the manufacturers of these drugs) are “mild and self-limiting” and consequently these drugs can be stopped with relative ease over a few weeks. The studies informing these guidelines were conducted by the manufacturers of these drugs and examined people who had only been on antidepressants for 8 weeks or so. We know now that people who are on antidepressants for longer than a few weeks — the vast majority of people who take antidepressants, with many on them for years or even decades — are much more likely to have severe and long-lasting withdrawal symptoms on stopping, which can sometimes be debilitating.
As a consequence, unfortunately, the traditional methods to stop antidepressants in guidelines are not an appropriate fit for many people and they can cause significant trouble when stopping. This means that well-intentioned medical professionals like general practitioners following these guidelines can advise tapers that are too quick and not scientifically informed to their patients. Sometimes these practitioners will diagnose relapse of someone’s underlying mental health condition because they lack awareness of withdrawal symptoms.
The field of deprescribing (safely stopping medications) is a relatively new field and highly specialized. The vast majority of medical training focuses on starting rather than stopping a medication, and many patients have reported unsatisfactory programs for discontinuing antidepressants. Many also end up seeking advice from online peer forums rather than their clinicians. There have been advances in how to safely stop antidepressants based on research done in Britain, which has led to updated guidelines there, but guidelines in North America remain antiquated.
The key to Outro’s methodology is this new approach — hyperbolic tapering — which is built on an understanding of the relationship between the dose of the drug and its effect on the brain (i.e. blocking of the serotonin transporter but also other receptor targets). Put simply, very tiny doses of antidepressants have outsized effects on the brain, meaning that people need to go down to very small doses before they can successfully stop their drug altogether. Imagine walking down a flight of stairs in the dark but the final steps are several meters high rather than just a few centimeters. This is the trap that traditional approaches to tapering these drugs have missed — and people can have terrible effects from crashing down those last few stairs. In Outro’s approach, we carefully navigate those tricky last few steps by using very small doses of medication so that people can ease off. Tapering more slowly reduces the intensity of withdrawal symptoms and gives time for the brain to adapt to the lower levels of the drug.
Can you tell us the backstory about what inspired you to originally feel passionate about this cause?
I was on antidepressants for 15 years and when I tried to come off them at the end of my Ph.D. in London (on how antidepressants work and the biology of depression) I struggled with severe withdrawal symptoms — the most awful experience of my life. I experienced panic attacks, dizziness, and suicidal ideation for the first time in my life. This was a short, sharp education into the incredible difficulties one can face when trying to stop these medications. I found there was a lack of support and knowledge from clinicians and researchers on how to safely stop antidepressants and the difficulties that can be encountered in withdrawal. Instead, I found an online community of many thousands of others struggling with the same things as I was dealing with, which was more helpful than some of the top professors in my field. Becoming aware of this massive knowledge gap led me to pursue both clinical work and research in the field of deprescribing psychiatric drugs, which eventually led me to co-found Outro. I would like others to have the support that was not available to me and to save people the ‘kitchen chemistry’ I was forced to pursue.
Many of us have ideas, dreams, and passions, but never manifest them. They don’t get up and just do it. But you did. Was there an “Aha Moment” that made you decide that you were actually going to step up and do it? What was that final trigger?
I am as risk-averse as the next person. I would prefer to have followed a conventional career path and completed my training along with my friends and colleagues — and this would make my anxious father much happier with me! However, when I had a life-changing experience when trying to come off of antidepressants — an experience so awful it made me consider ending my life — it was a wake-up call that these medications I had taken for so long myself and prescribed to patients without much of a second thought or much awareness of their actions were not as benign as I had been led to believe. When I realized the magnitude of people affected by these medications (millions around the world along with friends and family)and my ability to do something about it (having undertaken research training in psychiatry), I felt compelled to do something.
None of us can be successful without some help along the way. Did you have mentors or cheerleaders who helped you to succeed? Can you tell us a story about their influence?
I have been very lucky to have brilliant mentors and cheerleaders along the way. I encountered a very supportive professor of psychopharmacology in Britain, David Taylor, who through his own firsthand experience of antidepressant withdrawal symptoms, has been instrumental in helping me to communicate my work to a wider audience. I have been privileged to have worked with a professor of psychiatry, Joanna Moncrieff, who has taught me how to examine the evidence about medications from a clear-eyed perspective, without the fog of propaganda put out by the drug manufacturers.
I have also learned from the years of wisdom and learning of Adele Framer in this area, who took it upon herself when she found out that clinicians were mostly ignorant of issues of withdrawal from antidepressants to become an expert and take on the role of filling the hole in their practice. I have learned more from her about how to safely stop these medications than I did in more than a decade of formal psychiatry training at some of the top institutions in the world. I am delighted that I can continue to work alongside her in Outro which she has joined as the Head of Patient Advocacy. I have also been very grateful for all the support provided by hundreds of people trying to come off these drugs around the world who have taken the time to write to me to thank me for my contributions (something that never happened when I was studying brain cells in a dish!).
According to Mental Health America’s report, over 44 million Americans have a mental health condition. Yet there’s still a stigma about mental illness. Can you share a few reasons you think this is so?
I think the main reason that there is a stigma about mental illness is the very misleading way in which it has been communicated to the public, which has displaced much more intuitive humanistic understandings of why people become anxious and depressed. We are in the age of biology where there have been incredible advances in all fields of medicine through understanding the biology of various illnesses.
The same hope was placed in biological research for psychiatry but the results have been disappointing and the approach more harmful than helpful overall. Although it was once thought that providing biological explanations for mental health problems would serve to reduce stigma — with the rationale that such an explanation would convey to people that their conditions were not their fault — studies have shown that this has back-fired and has increased stigma. This thinking is a result of what has been called the fallacy of the ‘brain or blame false dichotomy’: that either depression (or anxiety) is a result of a brain illness or else it is people’s fault. But this dichotomy is false because it is normal for humans to become depressed or anxious when under stress and when their needs for safety, community, support, and meaning are not met. It is not a sign of weakness.
Biological explanations for depression (e.g. the chemical imbalance theory of depression, which we have recently shown is not supported by evidence) tend to increase stigma, including self-stigma, make people feel more hopeless about improving, and are associated with greater levels of depression. This is because the message that is conveyed in such cases is that people have something fundamentally wrong with their brains (often referred to as a ‘broken brain’).
More evidence-based explanations for why people feel hopeless and depressed such as the circumstances in their lives (with the number of stressful life events correlating strongly with the risk of depression) are associated with less stigma. These also empower people to understand what has led them to these dark places and what can be done about it.
Although there is clearly a biological component to depression and anxiety — in influencing our personality for example — there has not been clear evidence that depression or anxiety can best be understood as a brain illness. Although in one sense, depression is ‘in the brain’, so are sadness, happiness, irritation, and hunger. We better understand these states by understanding what is happening to the person rather than understanding the state of their brain. Indeed, much of brain-based explanations of depression and anxiety can be thought of as a category error: like opening up the back of your computer’s hard drive when a computer program is not working. People’s moods, similarly, are best-made sense when understanding what are their particular stressors in life. This makes it easier to understand how to help them and also reduces stigma.
In your experience, what should a) individuals b) society, and c) the government do to better support people suffering from mental illness?
The main thing that people should understand to better help people with mental health difficulties is that all the research points to depression and anxiety (to stick to these very common mental health problems) arising from experiences in people’s lives and not faulty biology. It is by understanding these experiences and how to accommodate them or change them that gives people the best chance of dealing with their problems.
We need to re-educate people and society more generally so that common mental health problems can best be understood in terms of people’s circumstances and not in terms of their brain biology. This is not starry-eyed idealism, but simply what the research shows. The main drivers of mental health problems are poverty, inequality, insecure jobs, relationship conflict, racism, physical illnesses, and other things that undermine people’s basic emotional and physical needs. Rather than there being a renewed call for more mental health services or more biological research every time, there is a tragic suicide or a celebrity comes forward with their tale of mental health problems, what we need to do as a society is address the social drivers of despair and hopelessness.
As someone who has spent years working in neuroscience laboratories studying the brain in mental health conditions, this opinion will not endear me to my colleagues, but we do not need more neuroimaging or genetic studies, and we do not need new ‘breakthrough’ drugs. Rather, we need to work to provide security and safety to people through political action and social support and not confuse ourselves into thinking that social problems are medical problems.
What are your 5 strategies you use to promote your own well-being and mental wellness? Can you please give a story or example for each?
I am not sure if I am a brilliant example of self-care, but I try to get enough sleep, am very careful about my circadian rhythms and my exposure to light and dark at the right times, and I try to eat healthily, including incorporating a lot of intermittent fasting, as well as some exercise. The single most important thing I have done for my well-being and mental wellness over the last few years is to reduce my dose of antidepressants gradually. The overall improvement in my well-being has been pronounced — my daytime fatigue and serious difficulties with concentration and memory, which plagued me for years while on the medication (and which were diagnosed as various other conditions along the way), have improved and allowed me to be much more productive and sharp than when I was on the drugs.
What are your favorite books, podcasts, or resources that inspire you to be a mental health champion?
I think the most important books and resources in the mental health space and the ones that have inspired me the most strip away the unhelpful medicalization of mental health problems and re-connect such problems to life circumstances and a humanistic approach.
These books and thinkers include:
- Robert Whitaker’s Anatomy of an Epidemic and his website madinamerica.com. He has been featured on various podcasts.
- Professor Joanna Moncrieff’s A Straight Talking Introduction to Psychiatric Drugs: the truth about how they work and how to come off them. She blogs at joannamoncrieff.com and has also been featured on various podcasts.
- Dr. James Davies’ books on the social context for mental health problems and the role of psychiatric drugs Cracked and Sedated.
- Various works by Sami Timimi, John Read, Lucy Johnstone, and Peter Kinderman have all been very inspiring as well.
If you could tell other people one thing about why they should consider making a positive impact on our environment or society, like you, what would you tell them?
If you stand up for what you believe in, your life will become much more interesting than you could ever have imagined, and you will meet an extraordinary group of people along the way.
How can our readers follow you online?
This was very meaningful, thank you so much. We wish you only continued success on your great work!
About the Interviewer: Inspired by the father of PR, Edward Bernays (who was also Sigmund Freud’s nephew), Michelle Tennant Nicholson researches marketing, mental injury, and what it takes for optimal human development. An award-winning writer and publicist, she’s seen PR transition from typewriters to Twitter. Michelle co-founded WasabiPublicity.com.
