Mal C

This week I was accused of stigmatising people for describing the science behind “SSRI eyes,” the phrase patients, families and friends use on social media for vacant, glazed eyes and enlarged pupils on these drugs. I went into the scientific literature today. What it shows is both frightening and fascinating. The stigma accusations look even thinner once you read the papers. 5-HT receptors are present in the cornea, iris, ciliary body, lens and retina. The iris ciliary complex contains 5-HT1A, 5-HT2A/2C and 5-HT7 receptors. Those receptors help regulate pupil size, aqueous humour and the ocular surface. When an SSRI blocks the serotonin transporter, synaptic 5-HT rises in the brain and in tissues that were never the intended target. The pupil is a balance between two muscles. The sphincter constricts the pupil under parasympathetic control. The dilator opens it under sympathetic control. 5-HT7 receptors on the iris sphincter relax that muscle. The pupil opens because the constrictor loses tone. This is called passive mydriasis. Some SSRIs add a weak anticholinergic effect (especially paroxetine) which can push the same direction. Noradrenergic spillover (stronger with SNRIs and with paroxetine) can also stimulate the dilator. Several mechanisms can therefore enlarge the pupil at once. This is measurable and not anecdotal. In a controlled study of sertraline and citalopram versus placebo in healthy adults, both SSRIs produced an acute and sustained increase in pupil diameter. In another study using Scheimpflug imaging, people on SSRIs had significantly larger pupils than controls (about 3.5 mm vs 3.1 mm), whether they had been on the drug for weeks or for more than six months. The enlargement persisted for as long as the treatment continued. Larger pupils change how the eyes look. They let in more light, reduce depth of field and can make the gaze appear fixed or wide. In bright light the person may squint or look uncomfortable. In photographs the pupils stay relatively open when you would expect them to pin. That is one part of the glazed look. The other part is the ocular surface. SSRIs are independently associated with dry eye. Studies show shorter tear break up time, more corneal staining and higher symptom scores in people taking SSRIs compared with controls. One line of work found higher serotonin in the tears themselves. SSRIs can also interfere with the neural reflex that drives tear secretion. The film that should make the cornea glossy becomes unstable. A dry, poorly wetting surface plus a larger pupil is exactly what people mean by dull or glazed eyes. A few caveats: • Not everyone on an SSRI gets visible pupil change or dry eye. • Dose, drug, duration, other drugs and the anatomy of the eye can all have an impact on these side effects. My claim, backed by science and research, is that SSRIs can and do change the eyes through documented serotonergic effects on iris muscle, tear film and, in some people, intraocular pressure. That is why patients notice it, partners notice it and online communities keep using the same phrase. They are looking at a pharmacological effect that medicine has known about in specialist papers while often treating it as trivia in the clinic. Naming it is not stigma! * Written by me, with some sentences lifted from the research. I used AI to help locate some of the literature.

One of the cool things about developing self-awareness is you become harder to manipulate through fear, guilt, judgment, tribal identity etc.

I keep hearing Doctors don't know the harms of psychiatric drugs bc so many take psychiatric drugs themselves. Geezus. I wouldn't want anyone treating me on these drugs. I've lived experience of how incapacitating they actually are.

I've never been told by my Doctor, Psychologist or Psychiatrist that I am broken, defective, or faulty. Anti-psychs tell me that I am all the time. That says more about them than it does Psychiatry. It's pathetic. Fuck off with that shit & go deal with your internal shame.

@BrownSchool @WUSTL Are you aware that your Associate Professor @MorganCShields supports inflicting stigma on people living with Mental Ilness & is saddened by people being happy with their care? Is this in line with the ethics of your school?