Gunfire In the Streets

 

True crime television is very big in the United States right now.  It is well produced and, in most cases, more engaging than typical fictional crime dramas.  Much of it shows real time police work with body cam and camera crew footage.  It gives a generally good presentation of police officers and detectives including demands of the jobs and their disclosure of the emotional toll and empathy for crime victims.  A cross section of police departments are sampled and they represent themselves very well.  I have been consistently impressed with their degree of professionalism and approaches to solving crimes. 

The striking part of these videos is the level of violence on the streets of the US and what the police have to contend with.  There seems to be a pattern of reactivity that many people have that leads them to try to evade the police or physically resist their efforts to detain them at all costs.  These aggressive confrontations often occur for trivial reasons.  A common example is a routine traffic stop that turns into a high-speed chase and multiple collisions or a single high impact crash.  The person apprehended has suddenly gone from a misdemeanor crime or traffic ticket to multiple felonies and jail time. 

Nowhere is the escalation more evident than firearm related crimes. I have seen many of these situations where the first action taken by the offender is to open fire on the police.  Open the car door and start shooting.  Pull off the covers in bed and come out shooting.  Wrestle with two officers in close proximity to your girlfriend, get loose, grab a gun, and start shooting. Hole up in your house or apartment and when the police show up start shooting through the windows and walls.  I saw one episode where 96 rounds from an assault rifle were fired though the apartment walls at police officers on a stairway (they did not fire a single shot).  And all of that gunfire took less than a couple of minutes.

Any reader of this blog knows that I support reasonable gun laws, abhor the current trend to maximize the number of guns on the street, and see easy access to guns as a major public health problem.  I also dispel the conventional political wisdom on guns as only being problems in the hands of the mentally ill or people taking antidepressants.  Gun violence in this country is directly proportional to high gun density and lax gun laws.  True crime TV quickly reveals that the primary equation for gunfire on the streets is an angry young man with access to firearms.  I have seen about a hundred of them interviewed on these shows. Most have no clear explanation for what happened.  They uniformly regret that it did happen – mostly because the consequences they are facing. And nothing would have happened if there was no easy access to handguns.  What would have been a fistfight became a gunfight with somebody dead and somebody in prison for the rest of their lives.

Although, the sampling for the shows is undoubtedly biased toward the sensational – I decided to take a look at what has been researched and written about in terms of gunfire on American streets.  For context I have posted the tree stump from outside the Spotsylvania Court house.  At least it was in that spot when it was sawed off by gunfire during a battle in the Civil War in 1864.  It was subsequently sent to the Smithsonian where it is displayed today.  For scale, historians estimate that during the three-day Battle of Gettysburg – 6- 7 million rounds were fired from small arms and 50,000 artillery shells were fired from 630 cannons.  The combined weight of the bullets, shells, and gunpowder was about 569 tons.  That is a lot of gunfire considering the standard military rifle of the day was a single shot musket that fired a Minié ball. 

One of the main questions I thought about was how much gunfire exists on American streets today with much more liberal gun laws and firearms with high-capacity magazines.  How would a typical day on American streets compare with the Civil War figure?  Globally we know that Americans purchase about 15.5 -22.7M firearms (rifles, shotguns, handguns) per year over the past 5 years. According to a 2017 estimate from Small Arms Survey, US citizens held 393.3M legal and illicit firearms or about 120.5 firearms for every 100 citizens.  The next closest country was Yemen with 52.8 per 100 citizens.  No other high-income countries had more than 40 firearms per 100 citizens.  

Incredibly the government is prohibited by law from collecting data and statistics on ammunition purchases so it is typically estimated from financial reports.  According to those estimates, Americans purchase about 10-12B bullets per year. That is 1600 times the number of rounds fired in the bloodiest battle of the Civil War.  For a weight comparison, the metal projectiles from 10B 9mm rounds would weigh 82 Tons, the full cartridges 132 Tons.  Of course, within that number there are people who may fire thousands of rounds at a gun range and some people who may not fire a single round every year.  Some rounds will be fired from illegal firearms. Some rounds will be fired during hunting.  Is there any way to estimate how many gunshots may be a direct danger to the public?

There are several sources of information.  Public health statistics offer indirect data on the end results.   There are about 132 firearm related deaths per day.  40% are homicides and 57% suicides.  The remaining gun deaths are from accidental deaths, police shootings, and undetermined gun deaths.  Beyond that another 200 people are struck by gunfire each day. A total of 320 people per day are struck by gunfire in the US and killed or wounded.  For comparison during Vietnam War (1965–1973), an average of approximately 20 American soldiers were killed and 53 were wounded every day.

It is difficult to impossible to find valid estimate of all gunfire in the US on any given day.  Several sources extrapolate from 30M recreational shooters and 10M hunters hunting and shooting at target ranges every day.  That us typically in the range of millions of rounds fired each day.  Using the most conservative figure for ammunition purchased, that figure might be as high as 27M rounds per day across all settings (gun ranges, hunting, fatal and non-fatal shooting).  Acoustic detectors of gunfire are deployed in only 100 cities in the US. Some files of gunfire detection are publicly available but as difficult to read CSV files.  There is some controversy about whether these systems lead to more traffic stops in minority areas and I cannot locate any national estimates from these devices.  Two studies have documented that about 88% of acoustic detected gunshots were unreported to the 911 systems.   Some authors have also included celebratory gunfire as another source of gunfire on the streets.

As a physician interested in public health and reducing gun deaths – the only way any of this makes sense is political interference.  Gun extremism is a problem in this country.  It has been a progressive political force for the past 40 years.  It is the most likely reason for a lack of tangible data on total rounds of ammunition sold per year in this country or even more basic information about total gunfire occurring at all crime scenes in the US every year.  At every crime scene, all of the expended shell casings are marked, numbered and photographed.  Collecting and reporting that data to a central location would be an easy job in this era of information, even if it would be an underestimate (not all firearms eject expended cartridges). 

There is only access to the end result – gun deaths and injuries.  The politics is such that we have become desensitized to it – even though the rate of gun violence in the US is higher than the casualty rate in the Vietnam War.  That was a war that was protested as unnecessary, but nobody is protesting the unnecessary gun violence in this country.  It is being sold at the highest levels as the price we all must pay for the hallowed Second Amendment.  

If you watch true crime TV like I do – pay attention to the senseless gun violence. Pay attention to how much gunfire occurs and the setting.  Pay attention to what the veteran police officers say about it.  Most of those shows do a good job of showing the impact it has on families and the police officers. 

And ask yourself why we can’t do better.   

 

George Dawson, MD, DFAPA

 Image Credit:

This is an image of a tree stump that resulted when the tree was sawed off by small arms fire during a Civil War battle.  The details of that battle are from where it resides in the Smithsonian Institute.  

"Until May 12, 1864, this shattered stump was a large oak tree in a rolling meadow just outside Spotsylvania Court House, Virginia. That morning, 1,200 entrenched Confederates, the front line of General Robert E. Lee's Army of Northern Virginia, awaited the assault of 5,000 Union troops from the Second Corps of the Army of the Potomac. Twenty hours later, the once-peaceful meadow had acquired a new name, the Bloody Angle. The same fury of rifle bullets that cut down 2,000 combatants tore away all but twenty-two inches of the tree's trunk. Several of the conical minie balls (bullets) are still deeply embedded in the wood. Unusual objects of war, such as this tree stump, come to symbolize the horror and heroism of a great battle. Originally presented to the U.S. Army's Ordnance Museum by Brevet Major General Nelson A. Miles, the stump was transferred to the Smithsonian in 1888."

 

References:

1:  Carr J, Doleac JL. The geography, incidence, and underreporting of gun violence: new evidence using ShotSpotter data. Incidence, and Underreporting of Gun Violence: New Evidence Using Shotspotter Data (April 26, 2016). 2016 Apr 26.

2:  Hansen JH, Boril H. Gunshot detection systems: Methods, challenges, and can they be trusted?. InAudio Engineering Society Convention 151 2021 Oct 13. Audio Engineering Society.

3:  Kaufman EJ, Wiebe DJ, Xiong RA, Morrison CN, Seamon MJ, Delgado MK. Epidemiologic Trends in Fatal and Nonfatal Firearm Injuries in the US, 2009-2017. JAMA Intern Med. 2021;181(2):237–244. doi:10.1001/jamainternmed.2020.6696

2009–2017: ~120,232 firearm injuries/year, or 329 every day — comprising 34,538 deaths (~95/day) and 85,694 ED visits for nonfatal injury (~235/day)

4:  Kaufman EJ, Song J, Xiong R, Seamon MJ, Delgado MK. Fatal and Nonfatal Firearm Injury Rates by Race and Ethnicity in the United States, 2019 to 2020. Ann Intern Med. 2024 Sep;177(9):1157-1169. doi: 10.7326/M23-2251. Epub 2024 Jul 30. PMID: 39074371.

2019–2020: the burden rose to an average of 1 firearm injury every 4 minutes and 1 firearm death every 12 minutes — ~252,376 total injuries with 84,908 deaths over the two years (~346 injuries and ~116 deaths per day).

A key public-health caveat is that these figures capture people who are shot and wounded or killed, not all rounds fired — there is no comprehensive national surveillance system that counts total gunfire or nonfatal, uninjured shooting incidents; nonfatal shootings and firearm uses "far outweigh" homicides and suicide deaths

5:  Koper CS, Baas G, Taylor BG, Liu W, Sheridan-Johnson J. Validating open-source data on fatal police shootings against self-reports from a national sample of police agencies. Inj Epidemiol. 2025 Oct 21;12(1):68. doi: 10.1186/s40621-025-00625-6. PMID: 41121442; PMCID: PMC12538985.

A Few More Lost Pieces of the Antidepressant Discussion

 

There was a lengthy article in the New York Times 2 days ago on antidepressants (1).  The main premise of the article is that millions of children and young adults were prescribed antidepressants.  The antidepressants may have been effective for the crisis but now that they continue on them, they have side effects and want to discontinue them because they feel emotionally blunted and disconnected. The chemical imbalance trope was invoked several times.  The author proceeds to extend the argument to suggest that there are millions of people in this predicament, physicians are unwilling or unable to help, and HHS Secretary Robert F Kennedy (RFK) is going to solve the problem largely by reforming psychiatry purportedly by moving into the “rift between patient and doctor” and promising to “free the mental health of Americans from dependence on pills”.

I have addressed this issue in many places on this blog.  That includes my response to RFKs arguments, RFKs comparison of SSRI withdrawal to heroin withdrawal, and strategies to prevent the problem including exposing only those people to antidepressants who need them, using medications with lower withdrawal risk, and generally being aware of the problem. I have also written about how long the problem has existed, when the first review of the problem was written, and that it is a fundamental skill that all physicians should have. 

In the RFK response I was also able to find out that the detailed antidepressant tapering and transition instructions have been in the premier online medical resource UpToDate for at least 18 years. Any practicing physician with access has those details. The facts as they exist show that RFK does not have a rational or even reasonable approach to the problem.  His idea that antidepressants are overprescribed and impossible to stop obfuscates the real problems of undertreatment and both active removal of treatment resources while promoting more high-risk treatment by the Trump administration.  In brief, the RFK approach to mental health has taken a solvable problem of not enough resources and blown it up into another problem.

To be clear, I am not commenting on the anecdote in the New York Times piece.  I have no personal knowledge of the patients or families mentioned.  I think a presentation of any similar situations in medicine should raise the questions: Why is a treatment being continued if it is not at least partially effective for the symptoms?  Why is a treatment not discontinued if the patient or family would prefer, they not take it?  What other treatments were tried before a medication was tried and what other treatments were tried concomitantly?  Invariably that all comes down to the expertise of the physician and knowing that the primary role to give the best advice to the patient and not make up their mind for them.  It is their job whether to take it or not. Almost everybody I encountered in practice had a preference to not take any medications. They either changed their mind about that after a lengthy informed consent discussion or not.  Either answer was fine with me. 

A confounding factor in any longitudinal analysis of medication effects is how people adapt to medications over time.  The first time I discontinued a maintenance antidepressant was in 1986.  That patient was a blue-collar worker who had been on doxepin for many years for migraine headaches and depression.  When I started seeing him his main problems were fatigue and hypersomnia.  I tapered and discontinued the doxepin.  He did well and eventually told me that he did not realize it at the time but he felt like he had the flu while he was on doxepin and that resolved after it was stopped.

Just as people can be unaware of long-term side effects after years on any medication – they can also get habituated to the therapeutic effects. That is the main reason people need close follow up when medications have been discontinued. Those effects go far beyond treating the primary disorder. People will report not feeling as well, not thinking as clearly, and not being as mentally flexible as when they were taking the medication.  In some cases they will experience a recurrence of a secondary disorder that was treated by the antidepressant like migraine headaches or back pain.  None of the symptoms described are due to withdrawal or a clear recurrence of the primary disorder but they would prefer to stay on the medication.

My main concern with the antidepressant controversy is that it is essentially a polarizing political argument at this point.  As far as psychiatry goes, nobody is talking about psychiatry the way I practiced it, how my colleagues practiced it, or how I trained residents to practice it.  The idea that any medication is good or evil is absurd.  The idea that the prescribers of medication are forcing it on clueless unsuspecting patients for the benefit of the pharmaceutical industry is equally absurd.  The most absurd arguments is that RFK or antipsychiatrists are going to save everyone on an antidepressant or psychiatric medication.  How will that happen when all the evidence is ignored and you have the expertise of a political podcaster?

To end this post, I want to include an important part of the antidepressant argument that I have ignored until now and that is how many people stop taking them.  There is a constant drumbeat of how many people take them and inaccurate suggestions that too many take them, so why would I think people stop taking them?  For many years, I worked for a healthcare company and I was on their Pharmacy and Therapeutics (P&T) Committee.  As such we were gatekeepers for medications that would be listed on the health plan formulary and were available to subscribers. We assessed the scientific data on efficacy but also the cost. At some point we also discussed compliance (now referred to as adherence) to the prescribed medications.  We found that a significant number of people never refilled their second prescription for antidepressants. At that point we began sending out reminder letters about the importance of adhering to the medication until there was agreement with their doctor that they should stop.

This occurred in the time frame of about 1995-2005. It was a health plan wide initiative meaning that most of the antidepressants were prescribed by primary care doctors. Stigma and the stigma of psychiatric medications was still hotly debated. There was still active misinformation about psychiatry and psychiatric medications.  There is always a personal bias to not take medications unless they are absolutely necessary. In terms of pure antidepressant prescribing I am sure that in many cases they were prescribed unnecessarily for self-limited crisis situations.  The important information here is that large number of patients stop taking these medications and that is never discussed.  It would be in opposition to the usual political argument of excessive prescribing and an inability to stop.       

What would that look like at a national and international level?  A commonly cited statistic is that 50% or persons prescribed antidepressants discontinue them in the first 6 months although many of the studies have lower estimates (see table below).  There are also several studies that estimate population wide use of antidepressants as both a percentage of the population (2-4) and absolute numbers (5).  The 2023 National Health Interview Survey found 11.4% of all adults ≥18 took antidepressant medication. The total population is 269.8M people so that is about 31M people.  Based on the available discontinuation percentages of 22 to 42.9% that means in any given year – 6.82 to 13.2 million people stop taking antidepressants.  Considering that as many as half of the antidepressants starts are for conditions other than depression it is likely that as many people are starting antidepressants as stopping them.   At least some of the survey data indicates that some of the reasons for stopping has to do with negative press and misinformation (fear of dependence)  – a known factor in the nocebo effect.

 

The above estimate is just that.  Four of the 5 studies are surveys.  There is no patient level data on a national scale that looks specifically at the antidepressant discontinuation issue.

There is data that looks at what happens at the treatment level.  That comes from a Danish register study of 66,540 older adults aged 65 or greater treated for depression who received a first-time antidepressant prescription between 2006 and 2016 (7).  Register studies are observational but they have the advantage of detailed information at the individual patient level about interventions when the databases are linked to clinical and pharmacy information for nationwide health plans. In this study, 33.7% of patient stopped antidepressants within 6 months, 26.5% gradually stopped over a period of 2 years, and 39.8% were on antidepressants for the entire 3-year period.  They studied the social determinants of this antidepressant use and also compared use to the recommended guidelines for antidepressant treatment in Denmark. Those guidelines suggest at least 6 months of maintenance treatment after initial remission and 2 years of maintenance for recurrent depression.  One of the social determinants was living in a non-urban area and the authors suggest this may be related to access to mental health specialty care.

The interesting aspect of the information in the Danish study was the detailed information across three general trajectories of antidepressant use.  Those trajectories are commonly seen in psychiatric practice and are far more realistic than what is typically portrayed in the media.  That includes the NYTimes article.       

When you read an article like that one or one of the many I have noted in the past – ask yourself what you really learned.  Like all medications antidepressants have side effects.  In fact, I routinely advised patients was that one person in six or seven would not tolerate them at all either due to initial side effects or withdrawal effects.  In clinical practice or real life - I never met a patient who told me they liked taking medications of any type.  Neither of those factors was a deterrent to trying a medication for most people.  The reason is that they were seeing me was for a severe, life changing problem and they had tried many other interventions. The Danish study (7) showed that only about 3% of that sample was ever hospitalized for severe depression.  Those were the patients I was treating.  

The psychiatric treatment of people over time is a dynamic process. It generally involves more than just medication with close attention to psychological factors and necessary lifestyle interventions. It requires a close collaborative relationship between the patient and the psychiatrist that includes a focus on optimizing therapy, minimizing or eliminating side effects and paying close attention to patient preferences. With that general approach, nobody should regret taking a medication longer than they should.  Nobody should put up with significant side effects.  And nobody should take a medication that is not working.  All of that is open for discussion.

Where I come from there is no rift between the patient and the doctor for RFK to fill.  And if there was – he is the wrong man to fill it.  

      

 George Dawson, MD, DFAPA

 

References:

 

1:  Bromley C.  A Generation on Antidepressants Searches for the Exit.  New York Times.  August 7, 2026.

2: Brody DJ, Gu Q. Antidepressant Use Among Adults: United States, 2015-2018. NCHS Data Brief. 2020 Sep;(377):1-8. PMID: 33054926.

3:  Mojtabai R, Olfson M. National trends in long-term use of antidepressant medications: results from the U.S. National Health and Nutrition Examination Survey. J Clin Psychiatry. 2014 Feb;75(2):169-77. doi: 10.4088/JCP.13m08443. PMID: 24345349.

4: Fu G, Li M, Lang X, Luo M, Chen S. Trends in depression and antidepressants use by social determinants of health among adults in the United States: Data from NHANES 2005-2018. J Affect Disord. 2026 Feb 1;394(Pt B):120662. doi: 10.1016/j.jad.2025.120662. Epub 2025 Nov 10. PMID: 41224008.

5:  Chai G, Xu J, Goyal S, et al. Trends in Incident Prescriptions for Behavioral Health Medications in the US, 2018-2022. JAMA Psychiatry. 2024;81(4):396–405. doi:10.1001/jamapsychiatry.2023.5045

6:  Elgaddal N, Weeks JD, Mykyta L. Characteristics of adults age 18 and older who took prescription medication for depression: United States, 2023. NCHS Data Brief. 2025 Apr;(528):1-9. DOI: https://dx.doi.org/10.15620/cdc/174589.

7:  Ishtiak-Ahmed, K., Rohde, C., Köhler-Forsberg, O., Christensen, K.S. and Gasse, C. (2024), Depression Treatment Trajectories and Associated Social Determinants: A Three-Year Follow-Up Study in 66,540 Older Adults Undergoing First-Time Depression Treatment in Denmark. Int J Geriatr Psychiatry, 39: e70006. https://doi.org/10.1002/gps.70006.

 

Supplementary 1: The decision about medications is common in any country with the availability of advanced therapeutics.  I personally take three medications every day that I would prefer not to take. I have to self-monitor for side effects including blood pressure readings every day.  If a doctor tries to give me a temporary antibiotic prescription – I personally do a drug interaction check and let them know if that medication is compatible.  I decide to take the medication not because it makes me feel better every day but because I know the cumulative effects of not taking it are potentially very bad and therefore, I decide to take it.  I have experienced side effects and complications that I had to figure out myself and that doctors missed.  This is all part of what it means to take a prescription medication. 

All of the steps I take to protect myself are the same steps I took with any medication I prescribed for patients.

The MAGA GOP Against Anthony Fauci, MD...

 

The Lie	The Facts
Lie 1: "Fauci lied about masks." The Claim: repeatedly asserts Fauci intentionally lied to the public to manipulate them or that his changing guidance proved he was deceptive.	In March 2020 (the early weeks of the pandemic), public health officials—including Fauci—advised the general public against buying N95 surgical masks to prevent a severe shortage for front-line healthcare workers, given the initial belief that COVID-19 spread primarily through large droplets and surfaces. As airborne transmission and asymptomatic spread became clear in April 2020, guidance shifted to universal cloth mask-wearing. Scientific adaptation to new data was re-framed by critics as a malicious "lie."
Lie 2: "Fauci created/funded COVID-19 in Wuhan." The Claim:  Repeated claims state that Fauci personally authorized "gain-of-function" research at the Wuhan Institute of Virology that directly created the SARS-CoV-2 virus.	While the National Institutes of Health (NIH) did fund grants to EcoHealth Alliance for bat coronavirus research in China, independent scientific panels, the NIH, and intelligence reviews clarified that the specific bat coronaviruses studied under those sub-grants were genetically distinct from SARS-CoV-2 and could not have evolved into the pandemic virus. The political rhetoric, however, repeats the "Fauci created the virus" line to frame a public servant as a criminal perpetrator.  Some circles suggest there was homicidal intent.
Lie 3: "Fauci personally forced lockdowns and school closures." The Claim: characterizes lockdowns, school closures, and business restrictions as unilateral mandates handed down personally by "Dictator Fauci."	Under the U.S. federal system, public health mandates (closing schools, restricting indoor dining, stay-at-home orders) were legally enacted by state governors and local public health departments—not federal advisory scientists. Fauci served as an advisor whose task force issued recommendations, but he lacked any statutory executive power to pass laws or order closures. See Supplementary 7 (below).
Lie 4:  "Fauci lied when he said vaccines stop 100% of transmission." The Claim: Asserts that public health officials promised the original COVID-19 vaccines would permanently block all infection and transmission, calling subsequent variant breakthrough cases "proof of a lie."	Clinical trials in late 2020 measured efficacy against symptomatic disease (which was ~95% for original strains). While early real-world data showed significant reduction in transmission against original variants, the emergence of mutated variants (like Delta and Omicron) eroded protection against infection while maintaining strong protection against severe illness and death. The shift in viral evolution was reframed as a deliberate institutional falsehood.
Lie 5: “Fauci made millions of dollars directly off the COVID-19 pandemic.” The Claim:  made millions through secret royalty checks paid by pharmaceutical companies for COVID-19 vaccines. The claim frames him not as an independent public health scientist, but as a compromised figure using federal authority to enrich himself and corporate allies.  In this hearing there was a comments that he was “enriching himself through the use of federal employees.”  There has also been a longstanding complaint that Dr. Fauci is the “highest paid federal employee and he makes more than the President.”  That is true but it is full disclosure and according to federal regulations.	-Dr. Fauci holds no patents and receives no royalties related to any COVID-19 vaccines or treatments (including the Pfizer, Moderna, or Johnson & Johnson vaccines). -FOIA disclosures obtained by watchdog groups showed that the NIH and its scientists received third-party royalties for older, pre-pandemic medical innovations (such as early HIV/AIDS research from decades prior). However, sensationalist headlines falsely claimed that these past, unrelated payments were "COVID-19 vaccine profits." -Dr. Fauci has repeatedly stated—dating back to interviews with the Associated Press and BMJ in 2004/2005—that he attempted to refuse statutory royalty payments from earlier research (such as an interleukin-2 treatment developed for HIV/AIDS) because he felt it posed a potential conflict of interest.  Because federal law required the agency to issue the funds, Fauci pledged to donate 100% of his royalty payments to charity. -Federal Salary: As the former Director of the National Institute of Allergy and Infectious Diseases (NIAID) and Chief Medical Advisor, Dr. Fauci was one of the highest-paid federal civil servants, earning a fixed annual government salary (~$480,000 before his retirement in late 2022). This salary was set by federal civil service pay scales, completely independent of vaccine sales or corporate profits. - Public Filings: Under the Ethics in Government Act, Fauci’s financial disclosures—including his investments, stock holdings, and outside income—are subject to strict federal conflict-of-interest audits and are a matter of public record. His filings show no stock holdings in individual pharmaceutical companies; his personal investments are held in broad mutual funds, municipal bonds, and standard retirement accounts.  His income is subject to strict federal conflict-of-interest audits and is a matter of public record. His filings show no stock holdings in individual pharmaceutical companies; his personal investments are held in broad mutual funds, municipal bonds, and standard retirement accounts. -In February 2021, Tel Aviv University awarded Dr. Fauci the Dan David Prize for lifetime achievement in public health and his leadership during the HIV/AIDS and COVID-19 crises.  After tax withholdings and administrative fees, the direct deposit received by Fauci totaled $899,960.  The National Institutes of Health (NIH) ethics office has long-standing regulations (5 C.F.R. § 2635.204(g)) that allow federal researchers and doctors to accept bona fide, prestigious awards for scientific achievement from non-profit or educational institutions, provided the award is approved by an agency ethics officer.  Before accepting the Dan David Prize (and other academic honors throughout his 50-year career), Fauci submitted the award for official NIH ethics review, which formally authorized him to accept the cash prize.

I saw the various clips but don’t have to watch the entire debacle.  It was the usual exercise in rhetoric as I watched the US slide farther and farther from reality.  After all this was a debate about the COVID pandemic that officially ran from March 11, 2020 to May 5, 2023.  It has been over for more than 3 years.  The argument can easily be made there are more pressing public health and safety problems at this point ( foodborne illness outbreaks, vaccine preventable disease outbreaks (measles, pertussis), toxicology emergencies (lead poisoning), wildfires, that are direct  products of the policies of this administration and currently endanger thousands of Americans. 

In addition, the elimination of Medicaid and SNAP benefits endanger millions more.  Medicaid is the nation's largest payer of mental health and substance use disorder care, and the primary funding vehicle for addressing Social Determinants of Health (SDOH) (housing, food security, and transportation).  Medicaid is also the single largest payer of maternity care in the US covering 40% of all births. In the midst of those problems the HHS Secretary has decided that he knows something about mental health and has decided he knows more about what medications and treatments people with those disorders need to take.  So why is the pandemic being relitigated while this administration is ironically making American unhealthy again?

The most straightforward answer is because they can.  Trump and his allies have tapped in to strong anti-science, anti-knowledge, and anti-expert biases in the US and used them to their advantage.  They routinely scapegoat and vilify anyone who they consider to be an enemy or outsider and that is a very low bar.  To end up in the enemy camp – all you have to do is disagree with them.  Disagreement is easy when they have produced so many ideological decisions that have no rational basis.  The list of those irrational decisions can fill volumes at this point.  I will focus on the dynamics of the Fauci hearing.   

This hearing was clearly a set up by Paul, and Fauci made that point in his opening statement – specifically that Paul had an unhealthy obsession with him and had threatened to jail him. This is apparently because of Paul’s conspiracy theory that the COVID virus (SARS-CoV-2) was a virus modified in a Chinese lab and accidentally released.  He claims that Fauci knew something about this despite Fauci’s diary entry of 2021 documenting that the latest genetic information made manufacture in a lab an impossibility. The remainder of the hearing was essentially Fauci taking the Fifth Amendment against self-incrimination.  Anyone who knows how the government works would be foolish to start any discussion in such a biased proceeding. That is especially true in the case of Fauci who has a pardon from former President Biden. In this setting it is easy to suggest perjury incidents and file those charges in the absence of any real evidence for the original charge.

At least some of the impetus for these hearings was the personal diary of Dr. Fauci.  Paul apparently was given this access by HHS Secretary Kennedy who discovered it on their servers.  At this point I do not know if it was Dr. Fauci’s naiveté about recording personal notes on a government server or something else.  I do know that it is common sense that diaries are not written for public disclosure.  To publish this as Paul has done shows that it is all part of a general smear campaign and an attempt to suggest that the things nobody says out loud are really “lies”. 

Like almost all of the current governments tactics this all comes down to rhetoric at several levels.  The first is just the usual scapegoating and rage-bating.  Fauci is an intellectual, an elite, etc.  He is not like the rest of us but he likes to tell us all what to do.  This is our chance to rise up and throw him in jail.  Of course, the rage baiting caused more problems than that for Dr. Fauci and his family.  He has been threatened with harm and many of those threats were considered serious.  He had a government security detail from 2022 until it was terminated by Trump on January 24, 2025. It has not prevented further public threats in some cases by public figures who have no idea who Dr. Fauci is or what he has accomplished.  They are generally focused on one of the lies in the above table.

I thought about adding a section here on the academic references to the various rhetorical devices used by autocrats and fascists.  But I will keep it simple.  Trump and his administration use them all to distort reality, provoke anger in his base, and further divide the country.  One of his advisors was very clear about it and called it “flooding the zone.”  There is plenty written about that process in academic references, but you can see how it works in real time just by watching the news every day. Trump promotes the lie that the 2020 election was “stolen” and none of his cabinet nominees will answer that question in Congressional hearings.  Suddenly we have unconstitutional interference with local elections and pending federal legislation that will eliminate tens of thousands of eligible voters.

The pattern is clear.  Initiate a divisive issue, never admit it is false or involves any wrongdoing, and keep repeating it.  Ignore the fallout even if that includes casualties on the streets of Minnesota or in an unnecessary war.  Blame everyone else and never acknowledge mistakes even when they are obvious to everyone else. Academic references about logical fallacies are unnecessary in these scenarios. This is where the lies about Anthony Fauci come from.  When he was coming up with solutions to the horror of the pandemic, Trump and his cohort were suggesting bleach, ivermectin, and hydroxychloroquine – all completely ineffective and in some cases dangerous.  In fact with the “pile on” effect from this hearing one of those cabinet members took to social media to claim he had stockpiles of hydroxychloroquine that would have saved thousands of people.  That is another completely inaccurate claim.     

 In the final analysis. It all comes down to whether or not you are a rational person.  You may feel encapsulated by a Democrat or Republican label.  That clearly does not insulate you from unnecessary wars, the erosion of civil rights, the dismantling of the public health infrastructure, a deteriorating climate and environment, a worsening health care system, diversion of most economic resources to the wealthy, enabling convicted criminals and fraudsters to commit further crimes and trying to reimburse them for jail time, and using government resources to attack innocent American citizens.  It does not insulate you from the fact that we have an administration that has appointed people to serve in the cabinet who have no qualifications.  None of this passes muster as politics as usual much less rational decision-making.

So – be a rational person.  Respond to facts and not rhetoric. Notice when there is an appeal to your emotion rather than your decision-making. Recognize the obvious fallacies when you see them – like the frequent name-calling and witch hunts. 

Get the USA back on track again…

 

George Dawson, MD, DFAPA 

 

 

Supplementary 1:  The American Public Health Association (APHA) has come out on social media in support of Dr. Fauci.  Several medical organizations have done this in the past related to COVID and HIV controversies. It is time that every physician organization does the same thing and does it now.  I have been an elected official in physician organizations and there is always a “big-tent” concern.  In this case that would mean supporting Dr. Fauci would alienate any dues paying Republicans. As I hope to have pointed out in the above post – this is larger than political labels.  In the above table you can choose to be in column 1 or column 2.  Column 2 is the rational choice.  

Supplementary 2:  If you want to see how some of these lies played out in real time - I have a post here that recorded some of what football star Aaron Rodgers  had to say about Dr. Fauci back in 2024.  Mercifully the video has been taken down but the lies and distortions are still all there.  He goes even further suggesting that both the HIV and COVID pandemics were created to respond to only specific drugs and enrich Dr. Fauci and Pharma.  I am not saying that Rodgers is lying but he certainly is repeating them almost exactly as outlined in the above table.  The information to refute his assertions was widely available at the time and in the case of HIV for decades earlier. 

Supplementary 3:  Commentators on this issue always soft pedal any direct confrontation of the lie.  For exam on Lie #2 - Fauci funded the creation of the pathological COVID virus (already walked back by Sen. Paul to GOF and not the pandemic virus) it is common to hear:  "Well I don't agree with that but I do disagree with the way the pandemic was handled."  First off what part do you disagree with?  Fauci's job was keeping up with the research and trying to change guidance on the fly while hospitals were overwhelmed and tens of thousands of people were dying. Anyone in that situation is going to make what they consider to be the most conservative recommendation to save the most people.  Secondly, by making that hedging statement you are endorsing Lie #3.  Fauci did not personally close down anything.  That was all local officials.  

Supplementary 4:  I have a great interest in airborne viruses.  Because of that interest I documented the transition in thinking about COVID transmission from droplet nuclei to airborne on this blog.  The date was April 8, 2020.  This confirms row 1 in the table. 

Supplementary 5:  Highly recommend the nonpartisan Annenberg Foundation's FactCheck.org to fact check anything this party or administration has to say about Dr. Fauci or the COVID pandemic.

Supplementary 6:  Since I posted this around noon on August 1, 2026 I have heard the following in the media:

"Fauci is responsible for 8 or 9 millions deaths."

"Fauci is worse than Joseph Mengele."

And from a national comedian: "Of course Fauci lied about gain of function."

No he did not.  All of these statements confirm what is said in the body of my post and will probably be repeated every day if you are paying attention.  To be a rational person you have to be intentional.  All of these inaccurate statements cannot be brushed off or in the case of comedians - laughed at.  Pick a column and stay there.

8/2/2026:  Day 2 of the Fauci hysteria.  Many people have taken to social media to reinforce the message of the MAGA Republicans today portraying Fauci as a megalomaniac and blaming him for everything from vaccination side effects to their kid having to wear a dirty mask to school for 8 days in a row.  One of the worst examples I have seen was an excerpt posted about a meeting with a CIA official that supposedly informed him of a lab leak and suggesting he covered this up.  It is clear from the diary entry that he considered both the information and informant unreliable and actually suspicious.  This same author likened the situation to finding out Dick Cheney wrote in his diary that he knew there were no weapons of mass destruction in Iraq.  The huge problem with that comparison is not only what was recorded at the time (unreliable source) - but that genetic analysis of the virus showed it was not produced in a lab.  The real comparison here is from law enforcement and that is:  1:  eyewitnesses are unreliable and this informant would not even qualify as an eyewitness.  According to rules of evidence this is hearsay.  2:  In court - hearsay is not evidence, but genetic analysis is.  

And then there was this interview of RFK, Jr by CCN's Dana Bash.  It was full of misinformation including some of the misrepresentations in the table above.  Ashish Jha, MD provides a bit of commentary at the end and has the stunning disclosure that he now believes the pandemic virus was a lab leak.  I have searched everywhere for what he is basing that opinion on and so far have found nothing.  No matter what side of the issue you are on - all of this agitation does absolutely nothing to address either future outbreaks or the outbreaks that are occurring right now.  

 Supplementary 7:  A reminder of what actually happened and what the timeline was (see Lie #3).  States clearly ended emergency declarations before the dates declared by Trump HHS Secretary Azar,  Trump himself, and Biden ending it early.  Dr. Fauci was not in that loop.  Red states did it before Blue states and there was a mortality gap due to COVID with red states having a higher mortality. 

Feature	Federal Emergency Declarations	State Emergency Declarations
Primary Purpose	Funding, regulatory flexibility, and administrative waivers.	Direct police power over public movement, business operations, and health rules.
Scope	Unlocked federal funds (FEMA, CARES Act), allowed FDA Emergency Use Authorizations (EUAs), expanded telehealth, and provided extra Medicaid matching funds.	Enforced stay-at-home orders, indoor mask mandates, business closures/capacity limits, and school rules.
Jurisdiction	Did not have the legal power to issue nationwide lockdowns, close private businesses, or mandate masks for the general public.	Had direct legal authority under state constitutions to issue and enforce mandates.
The Two Federal Declarations The federal government established blanket, nationwide emergency statuses covering all 50 states: Public Health Emergency (PHE): Declared by HHS Secretary Alex Azar on January 31, 2020 under Section 319 of the Public Health Service Act. It officially ended on May 11, 2023 (6 days after the World Health Organization declared an end to the pandemic on May 5, 2023). National Emergency: Declared by President Donald Trump on March 13, 2020 (retroactive to March 1) under the National Emergencies Act and Stafford Act. President Biden signed a bipartisan congressional resolution ending it slightly early on April 10, 2023. State Actions: Florida:  April 30, 2020 (Stay-at-Home Order Ends): DeSantis issued a 30-day "Safer at Home" order on April 1, 2020. He allowed it to expire on April 30, 2020, initiating Phase 1 of state reopening on May 4.  September 25, 2020 (Lifting Business Limits & Banning Mask Fines): DeSantis moved Florida directly into Phase 3 reopening. This order: Removed all state-level capacity limits on restaurants, bars, and businesses.  Prohibited local municipalities from enforcing mask rules or public health orders with fines or penalties, effectively gutting local mask mandates.  May 3, 2021 (Invalidating All Local Mandates): DeSantis signed Senate Bill 2006 and issued an immediate executive order that canceled all remaining emergency orders and mask mandates passed by cities or counties statewide.  June 26, 2021 (State of Emergency Expires): DeSantis allowed Florida's official statewide COVID-19 State of Emergency to lapse without renewal.  July 30, 2021 (School Mask Mandates Prohibited): As schools prepared to reopen for the fall, DeSantis issued an executive order banning local school boards from requiring students to wear masks.  States That Ended Emergency Declarations Before Florida Michigan (October 12, 2020): The Michigan Supreme Court ruled in October 2020 that Governor Gretchen Whitmer lacked the legal authority to maintain executive emergency powers without legislative approval, effectively striking down the state of emergency early. Wisconsin (March 31, 2021): The Wisconsin Supreme Court struck down Governor Tony Evers’ emergency declaration, ruling he violated state law by repeatedly extending 60-day emergency orders without legislative consent. Alaska (April 30, 2021): Governor Mike Dunleavy allowed the legislature's extended public health emergency declaration to lapse on April 30, shifting the state into an administrative recovery phase. North Dakota (April 30, 2021): Governor Doug Burgum officially rescinded North Dakota’s executive order declaring a state of emergency at the end of April. Oklahoma (May 4, 2021): Governor Kevin Stitt issued an executive order terminating Oklahoma’s state of emergency in early May, citing falling cases and wide vaccine availability.

 

References:

1:  Rasmussen A.  RFK Jr is Asking to Be Proven Wrong Again So Here Are 40 Examples From Just One CNN Interview.  August 4, 2026:  https://rasmussenretorts.substack.com/p/rfk-jr-is-asking-to-be-proven-wrong

If you read one reference this is the one I recommend.  Dr. Rasmussen is a working academic virologist who knows more about these issues than anyone in the Trump administration or their affiliated media networks.  

2:  Gounder C.  Underlying Conditions https://www.celinegounder.com/

Dr. Gounder is an infectious disease specialist and epidemiologist and on this blog she exhaustively looks at the claims being made by politicians and whether or not they are accurate.  That include 3 parts on the Fauci hearing but also RFK's autism claims and the recent problems with food safety.  You should not be too shocked by the results.  

3:  Robertson L.  The Wuhan Lab and the Gain-of-Function Disagreement.   FactCheck.org.  Posted on May 21, 2021 | Updated on July 1, 2021  https://www.factcheck.org/2021/05/the-wuhan-lab-and-the-gain-of-function-disagreement/

4:  Robertson J, MacDonald J.  Fauci and Paul, Round 2.   FactCheck.org Posted on August 11, 2023 | Updated on August 23, 2024  Posted on July 22, 2021 | Updated on August 19, 2021 https://www.factcheck.org/2021/07/scicheck-fauci-and-paul-round-2/

“There’s no evidence that Fauci lied to Congress, as Paul asserted in the July 20 hearing, given that the NIH unequivocally backs up Fauci’s statement that the grant-backed research “was judged by qualified staff up and down the chain as not being gain-of-function.”

In a May 19 statement, NIH Director Dr. Francis S. Collins said that “neither NIH nor NIAID have ever approved any grant that would have supported ‘gain-of-function’ research on coronaviruses that would have increased their transmissibility or lethality for humans.”  “

5:  Jaramillio C, and Yandell K.  RFK Jr.’s COVID-19 Deceptions.  FactCheck.org Posted on August 11, 2023 | Updated on August 23, 2024  https://www.factcheck.org/2023/08/scicheck-rfk-jr-s-covid-19-deceptions/

6:  Kaiser J.  Under fire from Republican senators, Fauci takes the Fifth at COVID-19 hearing.  Science July 29, 2026:  https://www.science.org/content/article/under-fire-republican-senators-fauci-takes-fifth-covid-19-hearing

7:  American Society of Microbiology Letter in Support of Dr. Fauci.  July 28, 2026:  https://asm.org/articles/policy/2026/july/asm-letter-to-senate-committee-in-support-of-fauci

8:  The Bethesda Declaration: A Call for NIH and HHS Leadership to Deliver on Promises of Academic Freedom and Scientific Excellence:  https://www.standupforscience.net/bethesda-declaration

9:  Yamey G, Titanji B K. Fauci’s Senate hearing riled up the MAGA base—but at the cost of damaging public health BMJ 2026; 394 :e100529 doi:10.1136/bmj-2026-100529  https://www.bmj.com/content/394/bmj-2026-100529

 

A Realistic Comparison of SSRI and Heroin WIthdrawal

With all the quotes in the media about these withdrawal syndromes – I thought I would add a few facts.  These facts are based on science, my 22 years in acute care psychiatry, and another decade at a large facility specializing in substance use disorders.  I have been involved in the care of thousands of people with these disorders, and the care has improved substantially over that period of time largely due to the availability of Medications for Opioid Use Disorder (MOUD).  Before that there was a major problem treating anyone with an Opioid Use Disorder (OUD) if they were not enrolled in a methadone maintenance program. 

To cite a few examples, in acute care psychiatry it is common to receive emergency admissions of people with severe depression or psychosis.  Many have associated drug and alcohol problems.  In the case of heroin and other opioids, there was a rule extending up into the early 2000s that unless a person was enrolled in a methadone maintenance program, only acute detox could be done with methadone.  Additional medications were offered like clonidine to cover hyperadrenergic symptoms of opioid withdrawal.  Clonidine was often the only detox medication. The situation was not better in substance use disorder (SUD) treatment programs who often had an array of “comfort medications” designed to treat all of the peripheral symptoms of withdrawal.  The problem with this approach was twofold: first it was rarely adequate to treat acute withdrawal. Second, when the patient was discharged in a week, they had ongoing symptoms of withdrawal that essentially guaranteed an immediate relapse to opioid use.

The introduction of buprenorphine (Suboxone, Subutex, Sublocade) resulted in a marked improvement in the quality of care in this scenario. The acute and chronic withdrawal symptoms of opioids could be adequately treated and the risk of relapse mitigated. During the time of this transition, the large SUD treatment center where I was working went from using buprenorphine for acute detox to buprenorphine maintenance treatment.  I was responsible for treating depression and anxiety in these patients.  I observed that no matter what treatment I prescribed the anxiety, insomnia, irritability, and depression persisted for months as protracted opioid withdrawal symptoms until they were treated with buprenorphine.  At that point the withdrawal symptoms resolved immediately and completely.  The depression, anxiety, insomnia, and craving for opioids all resolved.  That massive improvement in care cannot be emphasized enough.  I went from discharging people after 1-3 months who I knew would relapse immediately to confidently discharging people who were stable and had a much better chance to recover.

I am posting this introduction because the historical window for this innovation was very brief and I doubt that many physicians ever saw it.  The advantage for patients was so clear that the medical director of the treatment program where I worked changed it from an abstinence-based program to MOUD.  The research at the time was clear.  MOUD saved lives by decreasing relapse rates, accidental overdoses, and decreased risk of infections (HIV, HCV).

In my previous post, I examined the rhetoric of comparing selective serotonin reuptake inhibitor (SSRI) withdrawal to heroin withdrawal.  But what about the popular myths and the science?  The popular view of opioid withdrawal is that once the acute phase is over – it is over.  The popular view promoted with SSRI withdrawal is that it is typically universal, severe, and long lasting.  Neither of those views are accurate.

The time course of symptoms is outlined in the diagram at the top of this post.  Acute symptoms have a characteristic pattern and can start as soon as hours after a last dose of heroin.  In the case of antidepressants, the time course is more dependent on the mechanism of action and half-life of the medication being studied. Since opioids are all mu opioid receptor (MOR) agonists – there are no known medications in this class that do not cause withdrawal, but what accounts for the differences in severity and percentages of people affected is not known. Pharmacokinetics and pharmacodynamics likely play a role – I will defer that discussion to later post.

The main qualitative differences in opioid and SSRI withdrawal are the lack of cravings and observable physical symptoms in SSRI withdrawal.  Opioids reinforce their own use and for that reason have street values.  SSRIs do not and have no street value. The withdrawal symptoms from SSRIs are largely subjective but that does not mean they are not real or serious.  

In the case of SSRIs and other antidepressants, the mechanism precipitating withdrawal is thought to be a precipitous fall in extraneuronal serotonin.  All SSRIs are orthosteric inhibitors of the serotonin transport protein (SERT).  Orthosteric inhibitors act like serotonin at the same binding site on SERT.  Allosteric modulators bind at a site that is topographically distinct from the site that the endogenous ligand (in this case serotonin or 5-HT) binds to.  Escitalopram has an additional effect on SERT as an allosteric modulator.  Trazodone, vilazodone, and nefazodone are all allosteric non-competitive inhibitors of SERT (1-4).  Withdrawal reaction have been described by both but not to the same degree as heroin withdrawal.   

In the case of heroin withdrawal, a series of studies done from 1962 to 1969 showed very high relapse rates (>90%) in heroin users who had been treated in a controlled environment. Thise studies led to early experiments with MOUD and eventually methadone maintenance.  A direct comparison of the likelihood of moderate withdrawal symptoms for each category is 3-31% for SSRIs and 100% for opioids.   Those numbers are qualified by several caveats.  First, opioid withdrawal has been studied for a much longer time, is more well characterized, and fewer medications are involved.  Second, study methodology for the SSRI withdrawal is much more varied from looking at short term randomized controlled studies to surveys of long-term use selected for withdrawal symptoms.  The former will underestimate withdrawal effects but identify a drug attributable effect by subtracting out placebo and the latter will overestimate effects .  The overestimate can be compounded by not subtracting a nocebo effect and publicity effects that may increase nocebo.  In clinical practice, using antidepressants with lower withdrawal risk – I found the incidence to be closest to that of Henzler, et al (7) at about one in six or seven people.    

In conclusion, discontinuing many medications can cause a withdrawal syndrome. Not all withdrawal syndromes indicate an addiction and some can be life-threatening.  They are difficult to study for several reasons.  First, the response to discontinuing the medication varies significantly from person to person even at the same dose and duration of use. That range is significant from no effect to severe and in some cases (alcohol, sedative hypnotics) life-threatening effects.  That includes a placebo response where that can be safely implemented.  Second, there is also a lack of high-quality evidence for many of these syndromes. The best evidence is for alcohol and sedative hypnotics because they are obvious and have been treated for decades.  But even then there are consensus guidelines such as the ASAM guideline on benzodiazepine tapering.  Third, there is limited standardization across guidelines.  Fourth, there are pharmaceutical limitations.  In some cases, very small doses of medication are needed to complete the protocol that may require a liquid form, pill cutting, or substitution with an equivalent medication with a longer half-life.  In some cases, all of these changes may not be enough.  Fifth, in clinical trials where medications were tapered and discontinued there may not be enough reported details to replicate the protocol in clinical practice (5).  Sixth, the outcomes of discontinuation of a medication are complex and include resolution of adverse drug effects, relapse to the treated condition, a unique withdrawal syndrome, or a rebound effect involving the physiological systems that were being treated – like rebound tachycardia after stopping beta-blockers.  Seventh, context is important especially with medications and substances that reinforce their own use.  Adherence to any tapering protocol on an outpatient basis is much less likely to happen.  Eighth, the medicolegal dimension may be a concern.  Because of the all of these factors, there is a lot of uncertainty involved in any tapering and discontinuation protocol.  There is seldom a protocol that will work well for everyone. Because of this risk some guidelines advise clinicians to seek legal or administrative consultation when attempting these protocols.  There is additional risk if relapse to the original condition occurs after a medication has been successfully stopped.

Despite all these concerns tapering and discontinuing medications is foundational medicine in any medical specialty. None of these problems are unique to psychiatry or medication for mental disorders.  As interns most physicians learning how to detoxify acute care patients with substance use disorders – the most common condition remains alcohol use disorder.  In their respective specialties – they learn more about how to do this with specific medications used in their specialty. That has resulted in protocols that can differ from hospital to hospital in the same town. In some cases, the protocols differ in the same hospital over a period of years.  To cite one example, I am aware of a hospital that used oxazepam followed by diazepam and then chlordiazepoxide or phenobarbital as their detox agents from alcohol and benzodiazepines. In some of the standard orders, anticonvulsants were also used to minimize seizure risk.

As more societies and government agencies get involved there is a gradual move to standardization.   Even if we get to that point – individual assessments and close monitoring will still need to be done.  The risk of a withdrawal syndrome from any medication is one that is necessary to medically treat various problems.  It is a decision that physicians and patients do not take lightly.  It is important to discuss that potential risk in the informed consent discussion.    

 

George Dawson, MD, DFAPA

 

References:

1:  Plenge P, Yang D, Salomon K, Laursen L, Kalenderoglou IE, Newman AH, Gouaux E, Coleman JA, Loland CJ. The antidepressant drug vilazodone is an allosteric inhibitor of the serotonin transporter. Nat Commun. 2021 Aug 20;12(1):5063. doi: 10.1038/s41467-021-25363-3. PMID: 34417466; PMCID: PMC8379219.

2:  Sanchez C, Reines EH, Montgomery SA. A comparative review of escitalopram, paroxetine, and sertraline: Are they all alike? Int Clin Psychopharmacol. 2014 Jul;29(4):185-96. doi: 10.1097/YIC.0000000000000023. PMID: 24424469; PMCID: PMC4047306.

3:  El-Kasaby A, Boytsov D, Kasture A, Krumpl G, Hummel T, Freissmuth M, Sandtner W. Allosteric Inhibition and Pharmacochaperoning of the Serotonin Transporter by the Antidepressant Drugs Trazodone and Nefazodone. Mol Pharmacol. 2024 Jun 18;106(1):56-70. doi: 10.1124/molpharm.124.000881. PMID: 38769018.

4:  Murray KE, Ressler KJ, Owens MJ. In vivo investigation of escitalopram's allosteric site on the serotonin transporter. Pharmacol Biochem Behav. 2016 Feb;141:50-7. doi: 10.1016/j.pbb.2015.11.010. Epub 2015 Nov 24. PMID: 26621784; PMCID: PMC4724252.

5:  Dirven T, Turner C, Thio SL, Blom J, Muth C, van Driel ML. Room for improvement in reporting of trials discontinuing long-term medication: a systematic review. J Clin Epidemiol. 2020 Mar;119:65-74. doi: 10.1016/j.jclinepi.2019.11.013. Epub 2019 Nov 29. PMID: 31786152.

6:  Goldberg JF, McIntyre RS, Swartz HA, et al. American Society of Clinical Psychopharmacology Task Force on the Deprescribing of Psychotropic Medications. Recommendations for the Deprescribing of Psychotropic Medications: A Consensus Statement From the American Society of Clinical Psychopharmacology Task Force. JAMA Netw Open. 2026 Feb 2;9(2):e260043. doi: 10.1001/jamanetworkopen.2026.0043. PMID: 41739481.

7:  Henssler J, Schmidt Y, Schmidt U, Schwarzer G, Bschor T, Baethge C. Incidence of antidepressant discontinuation symptoms: a systematic review and meta-analysis. Lancet Psychiatry. 2024 Jul;11(7):526-535. doi: 10.1016/S2215-0366(24)00133-0. Epub 2024 Jun 5. Erratum in: Lancet Psychiatry. 2024 Sep;11(9):e11. doi: 10.1016/S2215-0366(24)00253-0. PMID: 38851198.