![[dr. bob]](/dr-bob-sm.gif)
Dr. Bob is Robert Hsiung, MD,
bob@dr-bob.orgShown: posts 1 to 24 of 24. This is the beginning of the thread.
Posted by fido on February 26, 2015, at 20:34:17
Last year I was 4-5 months of Lexapro which didn't work.
When coming off I got brain zaps after a few days and felt sick. The brain zaps lasted as long as I got onto Anafranil. The brain zaps instantly vanished. After getting off Anafranil, which also didn't work, the brain zaps quickly came back!!
Then I got onto Cymbalta. The brain zaps vanished. Cymbalta didn't work. Now I have been off Cymbalta 2 days and the zaps are back and I feel really bad.This is starting to scare me. What if this doesn't go away anymore at all?!
I tapered down Cymbalta. I took like half a 30mg pill for a week. I thought maybe this would prevent the withdrawal symptoms from coming back but it didn't!This means I am basically forced to get back on a SSRI ONLY to get rid of the withdrawal! But once I stop the SSRI with brain zaps will come back and they will probably be even harder to get rid off the longer I have been on a SSRI.
What happens if you've been on a SSRI for years and then want to get off it? How are you supposed to do this without withdrawal?
Seriously, this isn't funny anymore.
I cannot walk around for weeks with these brain zaps hoping that one day they will get away.
Posted by fido on February 26, 2015, at 20:35:55
In reply to SSRI withdrawal symptoms really scare me!, posted by fido on February 26, 2015, at 20:34:17
Between anafranil and cymbalta I was like 3 weeks off meds and even in these 3 weeks the brain zaps did NOT go away!!!
I read stuff from people who had withdrawals for months of years! What if these brain zaps do not go away anymore at all!? This is scary.
Posted by Bill82 on February 27, 2015, at 0:39:45
In reply to Re: SSRI withdrawal symptoms really scare me!, posted by fido on February 26, 2015, at 20:35:55
I got them from buspar, stayed when I stopped it. Gradually over weeks they lessened in both frequency and feeling(not as zappy). As for how it is scary it is. When I smoked my first cigarette I got extremely high. Over time as I smoked this became less and less till it stopped. So I quit smoking. After couple months of not smoking tried again to get that high(helps with my ocd). Still didn't do anything. Guess our brains can be effected in little ways long after stopping a substance. Don't worry though you will be fine, best thing I found when brain zaps got bad was to take a nap, seemed to help a lot.
Posted by Robert_Burton_1621 on February 27, 2015, at 22:02:41
In reply to SSRI withdrawal symptoms really scare me!, posted by fido on February 26, 2015, at 20:34:17
> Last year I was 4-5 months of Lexapro which didn't work.
> When coming off I got brain zaps after a few days and felt sick. The brain zaps lasted as long as I got onto Anafranil. The brain zaps instantly vanished. After getting off Anafranil, which also didn't work, the brain zaps quickly came back!!
> Then I got onto Cymbalta. The brain zaps vanished. Cymbalta didn't work. Now I have been off Cymbalta 2 days and the zaps are back and I feel really bad.
>
> This is starting to scare me. What if this doesn't go away anymore at all?!
> I tapered down Cymbalta. I took like half a 30mg pill for a week. I thought maybe this would prevent the withdrawal symptoms from coming back but it didn't!
>
> This means I am basically forced to get back on a SSRI ONLY to get rid of the withdrawal! But once I stop the SSRI with brain zaps will come back and they will probably be even harder to get rid off the longer I have been on a SSRI.
>
> What happens if you've been on a SSRI for years and then want to get off it? How are you supposed to do this without withdrawal?
>
> Seriously, this isn't funny anymore.
>
> I cannot walk around for weeks with these brain zaps hoping that one day they will get away.
>Have you tried taking an SSRI with a long half-life as a "bridge" over the discontinuation period? I also experienced terrible brain zaps, nausea, and gastro-intestinal cramps when coming off paroxetine. I took fluoxetine the help with these symptoms for a month and had no further trouble. Fluoxetine (SSRI = prozac) has a half-life of around 5 weeks I think. It should work for getting off the cymbalta, too.
Posted by fido on February 28, 2015, at 12:18:16
In reply to Re: SSRI withdrawal symptoms really scare me! » fido, posted by Robert_Burton_1621 on February 27, 2015, at 22:02:41
Hello, no I havent tried prozac.
I dont really know what would be best now.
I mean should I try using prozac only to get rid of the symptoms? or should I try prozac as antidepressant and go really high?
I thought also about giving aurorix a chance. Maybe that could work. But on the other hand if I go on a reversible MAOI then I cant take anything for adhd. It's like with my symptoms (depression,ocd,anxiety,adhd) it's impossible to find a combo which is safe and treats all symptoms. :(
I feel really lost with all my questions and decisions to make. My pdoc cannot help me with this. I see him only every 8 weeks and then we have like 10 minutes to talk, it's WAY too little time. I cannot even discuss all that I would like to discuss. Basically the visits are all about getting off the old drug and getting on a new drug and that's it. :(
But I really dont think I can find a better pdoc who has more time. I have already tried a few and they are all more or less the same.
Posted by Robert_Burton_1621 on March 1, 2015, at 7:17:28
In reply to Re: SSRI withdrawal symptoms really scare me!, posted by fido on February 28, 2015, at 12:18:16
>Hello, no I havent tried prozac.
I dont really know what would be best now.
I mean should I try using prozac only to get rid of the symptoms? or should I try prozac as antidepressant and go really high?>These are, of course, questions for you and your doctor, but I don't see any obvious advantage to you in going on a therapeutic dosage of fluoxetine given that you have already tried an SSRI unsuccessfully.
I think that if the discontinuation symptoms are really bothering you, using a low dosage of prozac should help considerably. You could start straight away.
Alternatively, have you tried titrating down the cymbalta more slowly?
> I thought also about giving aurorix a chance. Maybe that could work.>
From what I hear from psychopharmacologists, moclobemide is not an effective medication. You might wish to pose that question separately on the forum. I tried aurorix very early on and it did absolutely nothing. In no sense is it comparable clinically to the irreversible MAOIs.
> It's like with my symptoms (depression,ocd,anxiety,adhd) it's impossible to find a combo which is safe and treats all symptoms. :( >
Impossible? Have you reached this conclusion through experience or were you advised to this effect by your doctor?
The OCD and anxiety may best be addressed by taking potent medication which acts primarily on serotonin, and the ADHD - if you cannot take or are not interested in taking Ritalin - may, as a second choice, be treatable by medication which inhibits the reuptake of noradrenalin.
Cymbalta and effexor do both of these things, but the problem with them is that their relative potencies as between serotonin and noradrenaline reuptake inhibition are fixed: you can't fiddle around in view of your response to them by increasing the effect of serotonin vis-a-vis noradrenaline and vice versa.
One solution to this fixed-potency issue is to combine two drugs whose potencies or action you *can* modify independently: an SSRI with a noradrenaline reuptake inhibitor, for instance.
The SSRI sertraline (zoloft) and the TCA nortriptyline combine very well. See, for instance: http://www.psychotropical.com/anti-depressants/general-intro-4
If you went straight on zoloft and nortriptyline, your discontinuaton symptoms would also be significantly, perhaps completely, mollified.
> I feel really lost with all my questions and decisions to make. My pdoc cannot help me with this. I see him only every 8 weeks and then we have like 10 minutes to talk, it's WAY too little time.>
That is totally inadequate time. I am sorry to hear you're restricted in this way. What country are you from?
Posted by fido on March 1, 2015, at 17:57:26
In reply to Re: SSRI withdrawal symptoms really scare me! » fido, posted by Robert_Burton_1621 on March 1, 2015, at 7:17:28
hello,
the problem is i have already tried wellbutrin for depression and adhd. it didnt work.
ritalin also doesnt work for adhd.
this means for adhd only amphetamines are left. strattera is very unlikely to work either.
and amphetamines again are risky when combined with ssri or snri because this can cause serotonin syndrome!
i really have NO clue what to do.
my current doctor is nice but he is simply way too busy. his waiting room is always full! often times a patient goes it and out in 5 minutes!
there is no room for much talking. basically it's all about simply deciding what drug to try next. he hardly knows anything personal about me. this bothers me.
but i already looked for other pdocs online and it's basically impossible to find out if there is a good one. i mean what shall i do? go to 10 different doctors and then see who's best?
also, among all pdocs in my area my current doc has the best reviews online. other doctors have worse reviews. i am not even going to a doctor who has bad reviews. :(
i feel really hopeless now. i am also scared of therapy. i tried therapy a few times and it always hurt me. i made very bad experiences. i cannot go to somebody who doesnt care and who only talks to me cause i pay him. this doesnt help me at all.
Posted by Robert_Burton_1621 on March 1, 2015, at 18:21:35
In reply to Re: SSRI withdrawal symptoms really scare me!, posted by fido on March 1, 2015, at 17:57:26
> hello,
> the problem is i have already tried wellbutrin for depression and adhd. it didnt work.Wellbutrin is not necessarily the most effective noradrenaline reputake inhibitor.
> ritalin also doesnt work for adhd.
> this means for adhd only amphetamines are left. strattera is very unlikely to work either.Why do you conclude that straterra is unlikely to work?
> and amphetamines again are risky when combined with ssri or snri because this can cause serotonin syndrome!
But what is the degree of risk when the combination is taken under supervision. Amphetamines have been adminstered, with care, with MAOIs for 40 years.
> i really have NO clue what to do.
Some have given you some suggestions. Perhaps consider these. GIve yourself some time to think about them.
> but i already looked for other pdocs online and it's basically impossible to find out if there is a good one. i mean what shall i do? go to 10 different doctors and then see who's best?I feel your frustration. Sometimes, that is the position we are all in with psychiatrists. It does take trial and error to find a pharmacologically competent, decent, and attentive one. If you do see another person, try to become clear after each session whether he or she is really helping you. If they are not, and if you've been reasonable in giving enough time for strategies to work, do not be afraid to stop with them and seek alternative care.
> also, among all pdocs in my area my current doc has the best reviews online. other doctors have worse reviews. i am not even going to a doctor who has bad reviews. :(Online reviews are hardly definitive. Can you not seek the advice of a primary care physician (GP?)
> i feel really hopeless now. i am also scared of therapy. i tried therapy a few times and it always hurt me. i made very bad experiences. i cannot go to somebody who doesnt care and who only talks to me cause i pay him. this doesnt help me at all.
Try as best as you can to place this fear in perspective. It does seem that getting your medication right first is what you should prioritise. Perhaps therapy may be beneficial for you when you and your doctor hit on a medication, or medication combination, that works for you.
Incidentally, what is the book you read on treatment resistance? I am interested in consulting it.
Best wishes.
Posted by fido on March 1, 2015, at 18:35:23
In reply to Re: SSRI withdrawal symptoms really scare me! » fido, posted by Robert_Burton_1621 on March 1, 2015, at 18:21:35
hello,
the book is in german so except you can read german giving you the name of the author will probably not be much help. it's from a female professor woggon. a swiss psychiatrist who treats hard cases.but neither wellbutrin nor cymbalta worked for me. they both work on noradrenalin. because of this i rather think that noradrenalin uptake inhibitors dont work for me. i could try strattera of course but i am also scared of withdrawal. since i got withdrawal from ssris i am now more afraid of drugs. i mean all the time nothing worked for me but i also got no side effects. but now i have the brain zaps. this makes me feel even worse.
what do you mean with "when the combination is taken under supervision"? a serotonin syndrome can happen at any time from what i read. it can kick in weeks after starting the treatment. this is very scary! i also dont even know if my doctor would even dare to prescribe ssri+amphetamines when there is a risk. he might as well say this is too risky for him.
i just googled psychiatrists in my area. there are a few ones with good reviews but this also doesnt have to mean that they really are good.
what i fear is that going to other doctors and getting different opinions will leave me totally clueless. i mean what if i go to a new doctor and he suggests something totally different or something which scares me? then how do i decide what to do? or what if he wants to send me to a mental institution? this wouldnt help me AT ALL.
it would only make me feel worse. but many doctors simply say this. if they dont know how to help they simply say you gotta go to a mental hospital for a few weeks. but this is nothing for me. this would not solve ANY of my problems. i would go there and suffer and probably get worse.
Posted by baseball55 on March 1, 2015, at 19:55:13
In reply to Re: SSRI withdrawal symptoms really scare me!, posted by fido on March 1, 2015, at 18:35:23
> what do you mean with "when the combination is taken under supervision"? a serotonin syndrome can happen at any time from what i read. it can kick in weeks after starting the treatment. this is very scary! i also dont even know if my doctor would even dare to prescribe ssri+amphetamines when there is a risk. he might as well say this is too risky for him.
I took an SSRI and adderall with no problem. I don't think the combination causes serotonin syndrome. Where did you hear that?
Posted by Robert_Burton_1621 on March 1, 2015, at 23:05:25
In reply to Re: SSRI withdrawal symptoms really scare me!, posted by baseball55 on March 1, 2015, at 19:55:13
> > what do you mean with "when the combination is taken under supervision"? a serotonin syndrome can happen at any time from what i read. it can kick in weeks after starting the treatment. this is very scary!>
What I mean is that the risk, to the extent that it exists, can be reduced to the negligible if the dosages are handled right.
> I took an SSRI and adderall with no problem. I don't think the combination causes serotonin syndrome. Where did you hear that?
>Good question. Amphetamine acts mostly on noradrenaline and dopamine, and
its serotonergic potential is very weak. There appears to be very little risk of causing serotonin toxicity when combined with an MAOI, for instance (although other risks, like noradrenergic toxicity, are more significant and were probably the cause of the few fatalities associated with the combimation of MAOIs with amphetamines). This does not mean the combination is risk-free; it means that the risk must be limited and monitored if the therapeutic option is to be pursued.Dr Gillman, an international authority on serotonin toxicity, writes that "amphetamine is 50-100 times less potent for serotonin, both as a releaser and reuptake inhibitor, than for dopamine or noradrenaline (see table). Its 5-HT transporter affinity (~3800 nmol) is extremely weak." But he also does note that a rise in central serotonin levels has been documented in animal studies and that "amphetamine exhibits significant toxicity with venlafaxine (probably serotonin toxicity, as opposed to noradrenergic toxicity)". See:
http://www.psychotropical.com/serotonin-toxicity
http://www.psychotropical.com/maois-and-cns-stimulants
Posted by Robert_Burton_1621 on March 1, 2015, at 23:53:52
In reply to Re: SSRI withdrawal symptoms really scare me!, posted by fido on March 1, 2015, at 18:35:23
> hello,
> the book is in german so except you can read german giving you the name of the author will probably not be much help. it's from a female professor woggon. a swiss psychiatrist who treats hard cases.
>Ok, thanks, no I don't read German unfortunately.
> but neither wellbutrin nor cymbalta worked for me. they both work on noradrenalin.>
But you are considering taking strattera, which is a selective NRI.
In regards to cymbalta, you can't really play around with the relative potencies of serotonin vs noradrenaline because, as I said in an earlier post, they are fixed. Because you have co-morbid depression and anxiety, perhaphs the combination of sertraline (SSRI) with a TCA which acts powerfully on noradrenaline (nortriptyline) might be worth trying out.
See: http://www.psychotropical.com/anti-depressants/general-intro-4
Below is some information on TCAs for ADHD. You do not appear ever to have tried any TCAs. Note that you most certainly cannot combine all TCAs with any SSRI - definitely ruled out in the former category are TCAs with significant serotonin reuptake inhihibition, like clomipramine, and in the later category(usually) paroxetine, fluoxetine and fluvoxamine because of interaction with P450 enzymes.
http://www.ncbi.nlm.nih.gov/pubmed/22303520
http://www.ncbi.nlm.nih.gov/pubmed/11052409
http://www.ncbi.nlm.nih.gov/pubmed/8428873
http://www.ncbi.nlm.nih.gov/pubmed/8444763
http://psycnet.apa.org/psycinfo/1995-18598-001
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2518387/ (desipramine)
> what i fear is that going to other doctors and getting different opinions will leave me totally clueless. i mean what if i go to a new doctor and he suggests something totally different or something which scares me? then how do i decide what to do? or what if he wants to send me to a mental institution? this wouldnt help me AT ALL.
> it would only make me feel worse.Are you not already in a state of confusion because you are not receiving the benefit of good psychiatric care? While there is a possibility that going to an alternative doctor may exacerbate this confusion, I would suggest that there is a greater possibility that some of your confusion at least may be dissipated by receiving competent advice and guidance.
Is the possibility of being institutionalised involuntarily a real one? Or is this a possible voluntary option for a short period?
Posted by Robert_Burton_1621 on March 2, 2015, at 0:11:02
In reply to SSRI withdrawal symptoms really scare me!, posted by fido on February 26, 2015, at 20:34:17
> When coming off I got brain zaps after a few days and felt sick. ....Then I got onto Cymbalta. The brain zaps vanished. Cymbalta didn't work. Now I have been off Cymbalta 2 days and the zaps are back and I feel really bad.
>
> This is starting to scare me. What if this doesn't go away anymore at all?!This is not a discontinuation symptom that you should considered to be clinically or medically "scary".
> This means I am basically forced to get back on a SSRI ONLY to get rid of the withdrawal! But once I stop the SSRI with brain zaps will come back and they will probably be even harder to get rid off the longer I have been on a SSRI.
>I don't think this is true. One reason the discontinuation symptoms began so soon (after three or four days off each of your medications), is because of their relatively short half-lives. If you bridge for a month using a small dose of an SSRI with a very long half-life, like fluoxetine, you are likely to find that you have no brain zaps while you are on it and none when you come off. That was my experience precisely and I have no continuing issues at all after having had SSRI therapy for 5 or 6 years.
Posted by fido on March 2, 2015, at 16:55:41
In reply to Re: SSRI withdrawal symptoms really scare me!, posted by Robert_Burton_1621 on March 2, 2015, at 0:11:02
@ baseball
Go to drugs.com and search for adderall + ssri. They warn you of serotonin syndrome. I also checked other medical interaction websites they also mention the risk. Also, there are REAL cases of SS when mixing adderall + ssri/snri.
I don't really care what Gillman writes. The fact that SS happened under this combo means that there is a risk!
And this is already enough to scare me. I dont want to live in fear of SS all day and then check myself all the time and become worried if I get a muscle twitch or something like that. Even from SSRI alone I used to get muscle pulsations which worried me.
I mean I cant go to the ER whenever I feel like I might have some symptoms of SS. I can do this once and the second time they will already think I'm a hypochondriac and not treat me anymore.
And I also dont know if my pdoc can tell me much about SS and what symptoms to look for. I think that if I tell him about the possible risk when mixing amphetamines + ssri then he will simply say that I cannot use amphetamines cause of the risk. But ritalin doesnt work for adhd and adhd is also a huge issue for me. I think that my lack of motivation is also a big hinderance for me. I have not been able to get myself to work for months now even though I am under time pressure and it only gets worse.
For me even starting to work is always a struggle. :(@ robert
I tried anafranil and 75mg were already too much. It made my heart race. This is why my doc said that I can forget about other TCA cause they all would do the same cause they all have the same antichol. side effects. I fear that he is right.
When taking TCAs you usually need a dosage of at least 150mg! But I couldnt even stand 75mg.I also dont know if a combo like SSRI + nortriptyline would be better than SSRI + wellbutrin or SSRI + strattera. Strattera scares me somehow. I read it can make you suicidal.
Wellbutrin on the other hand failed me at 300mg.
This is why I have not much faith that it would work in a combo with a SSRI.
But nortrip on the other hand would have much more side effects as a TCA. Wellbutrin at least had no side effects. :/
Posted by Robert_Burton_1621 on March 2, 2015, at 17:51:52
In reply to Re: SSRI withdrawal symptoms really scare me!, posted by fido on March 2, 2015, at 16:55:41
> Go to drugs.com and search for adderall + ssri. They warn you of serotonin syndrome. I also checked other medical interaction websites they also mention the risk. Also, there are REAL cases of SS when mixing adderall + ssri/snri.
> I don't really care what Gillman writes. The fact that SS happened under this combo means that there is a risk!Drugs.com will say incorrectly that many combinations can cause serotonin syndrome. It says mixing mirtazapine with venlafaxine carries the "major" risk of serotonin syndrome! This is just erroneous. Mirtazapine has been used to treat serotonin syndrome.
I feel, from my perspective, that it is better to take into consideration well-evidenced information by people who have expertise in this particular area, than to rely reflexively on sites like drugs.com, but that is of course a matter for you and your doctors.
Amphetamines at the right dose are so low in their serotonergic potential that the risk, if any, is low. But it seems that your current conditions and the inadequate experiences you've had with psychiatrists may be predisposing you to overestimate any risks and underestimate the relative efficacy of potential treatment options.
> I tried anafranil and 75mg were already too much. It made my heart race. This is why my doc said that I can forget about other TCA cause they all would do the same cause they all have the same antichol. side effects.
It is not correct to advise that all TCAs have the same degree of side-effects as clomipramine. Clomipramine is usually very effective for OCD but it carries a high degree of TCA-related side-effects. Nortriptyline does not carry them to the same extent, much less.
> I also dont know if a combo like SSRI + nortriptyline would be better than SSRI + wellbutrin or SSRI + strattera. Strattera scares me somehow. I read it can make you suicidal.
The combination of SSRI and strattera may be worth trying. In regards to suicide, most anti-depressants now carry generic advice warning about an increase in suicidal thoughts.
> But nortrip on the other hand would have much more side effects as a TCA. Wellbutrin at least had no side effects.
>Nortriptyline has fewer side-effects and to a lesser degree than clomipramine, for instance.
Posted by Lou Pilder on March 3, 2015, at 19:54:06
In reply to Re: SSRI withdrawal symptoms really scare me! » fido, posted by Robert_Burton_1621 on March 2, 2015, at 17:51:52
>
> > Go to drugs.com and search for adderall + ssri. They warn you of serotonin syndrome. I also checked other medical interaction websites they also mention the risk. Also, there are REAL cases of SS when mixing adderall + ssri/snri.
> > I don't really care what Gillman writes. The fact that SS happened under this combo means that there is a risk!
>
> Drugs.com will say incorrectly that many combinations can cause serotonin syndrome. It says mixing mirtazapine with venlafaxine carries the "major" risk of serotonin syndrome! This is just erroneous. Mirtazapine has been used to treat serotonin syndrome.
>
> I feel, from my perspective, that it is better to take into consideration well-evidenced information by people who have expertise in this particular area, than to rely reflexively on sites like drugs.com, but that is of course a matter for you and your doctors.
>
> Amphetamines at the right dose are so low in their serotonergic potential that the risk, if any, is low. But it seems that your current conditions and the inadequate experiences you've had with psychiatrists may be predisposing you to overestimate any risks and underestimate the relative efficacy of potential treatment options.
>
> > I tried anafranil and 75mg were already too much. It made my heart race. This is why my doc said that I can forget about other TCA cause they all would do the same cause they all have the same antichol. side effects.
>
> It is not correct to advise that all TCAs have the same degree of side-effects as clomipramine. Clomipramine is usually very effective for OCD but it carries a high degree of TCA-related side-effects. Nortriptyline does not carry them to the same extent, much less.
>
> > I also dont know if a combo like SSRI + nortriptyline would be better than SSRI + wellbutrin or SSRI + strattera. Strattera scares me somehow. I read it can make you suicidal.
>
> The combination of SSRI and strattera may be worth trying. In regards to suicide, most anti-depressants now carry generic advice warning about an increase in suicidal thoughts.
>
> > But nortrip on the other hand would have much more side effects as a TCA. Wellbutrin at least had no side effects.
> >
>
> Nortriptyline has fewer side-effects and to a lesser degree than clomipramine, for instance.
>
> R_B_1621,
You wrotes,[...drugs.com will say incorrectly...this is just erroneous...Mirtz has been used to treat SS...].
Then if Mirtz is *not* used to treat SS, then Drugs.com is not saying incorr4ectly and what they print is not erroneous?
Lou>
Posted by Robert_Burton_1621 on March 3, 2015, at 20:37:05
In reply to Lou's request-wrklez » Robert_Burton_1621, posted by Lou Pilder on March 3, 2015, at 19:54:06
I don't follow your logic, Lou.
Posted by fido on March 3, 2015, at 21:02:13
In reply to Lou's request-wrklez » Robert_Burton_1621, posted by Lou Pilder on March 3, 2015, at 19:54:06
@ robert
I heard the argument that SSRI + Nortrip is better than Cymbalta for example cause you can do finer adjustment. This sounds logical. But how shall I even know if I need more NE or more Serotonin? I mean if I go on such a combo and don't feel better then I can't tell what the problem is, wether I need more of both or only more of 1 thing. I don't really know if in reality the fine adjustment stuff really pays off. When you have 2 variables then this makes finding the "right dose" even harder and I dont have time to take a combo for months and try out all kinds of dosages. I needed to find something which works asap.
What I also worry about is how harmful it is to the brain if I check out many drugs in short time. I think that from now on I will not take any AD longer than 4-5 weeks maximum. I don't have that much time and I also don't want to risk getting withdrawals. The longer you're on a drug the bigger the risk.
But if I go from 1 drug to the next every month then I don't know what this does to the brain. I cant imagine that it's very healthy. But on the other hand I really have to find something which works fast. My ex-pdoc cost me a lot of time by stalling and raising my dosages very slowly. From now on I'll take care of dosing myself. I will get the prescription and then slowly raise the dosage within the normal ranges. It makes no sense to stay on a dose which doesnt work until the next appointment only to be told to raise the dose.
Posted by Lou Pilder on March 4, 2015, at 5:42:21
In reply to Lou's request-wrklez » Robert_Burton_1621, posted by Lou Pilder on March 3, 2015, at 19:54:06
> >
> > > Go to drugs.com and search for adderall + ssri. They warn you of serotonin syndrome. I also checked other medical interaction websites they also mention the risk. Also, there are REAL cases of SS when mixing adderall + ssri/snri.
> > > I don't really care what Gillman writes. The fact that SS happened under this combo means that there is a risk!
> >
> > Drugs.com will say incorrectly that many combinations can cause serotonin syndrome. It says mixing mirtazapine with venlafaxine carries the "major" risk of serotonin syndrome! This is just erroneous. Mirtazapine has been used to treat serotonin syndrome.
> >
> > I feel, from my perspective, that it is better to take into consideration well-evidenced information by people who have expertise in this particular area, than to rely reflexively on sites like drugs.com, but that is of course a matter for you and your doctors.
> >
> > Amphetamines at the right dose are so low in their serotonergic potential that the risk, if any, is low. But it seems that your current conditions and the inadequate experiences you've had with psychiatrists may be predisposing you to overestimate any risks and underestimate the relative efficacy of potential treatment options.
> >
> > > I tried anafranil and 75mg were already too much. It made my heart race. This is why my doc said that I can forget about other TCA cause they all would do the same cause they all have the same antichol. side effects.
> >
> > It is not correct to advise that all TCAs have the same degree of side-effects as clomipramine. Clomipramine is usually very effective for OCD but it carries a high degree of TCA-related side-effects. Nortriptyline does not carry them to the same extent, much less.
> >
> > > I also dont know if a combo like SSRI + nortriptyline would be better than SSRI + wellbutrin or SSRI + strattera. Strattera scares me somehow. I read it can make you suicidal.
> >
> > The combination of SSRI and strattera may be worth trying. In regards to suicide, most anti-depressants now carry generic advice warning about an increase in suicidal thoughts.
> >
> > > But nortrip on the other hand would have much more side effects as a TCA. Wellbutrin at least had no side effects.
> > >
> >
> > Nortriptyline has fewer side-effects and to a lesser degree than clomipramine, for instance.
> >
> > R_B_1621,
> You wrotes,[...drugs.com will say incorrectly...this is just erroneous...Mirtz has been used to treat SS...].
> Then if Mirtz is *not* used to treat SS, then Drugs.com is not saying incorr4ectly and what they print is not erroneous?
> Lou
>
> > Robert,
You say that you do not follow my logic. I say to you that what you have posted here could result in the deaths or addictions or life-ruining conditions to other readers here and I am asking that we have an immediate discussion here. This is all because the psychiatrist that operates this forum is allowing your claims here to be seen as supportive and I think otherwise, and your claim that Mirtazapine is used to treat SS, and that the site drugs.com has erroneous information is what is in issue here.
If you could post answers to the following then by my responses I could address your claims here in what I think could save lives, prevent life-ruining conditions and addictions.
True or false:
A. The interactions section of drugs.com is not based on facts.
B. I know that the site drugs.com has false information and I will post here a citation that shows that.
C. I really don't know if the site drugs.com has erroneous information about interactions, Lou. I posted that in order to get the person that I am in discussion with to ignore the sites information that says that SS could result in taking the combination.(which could lead to death)
D. I cited that Mirtazapine is used to treat SS without posting a citation to support that claim , Lou, because the only reference is an unreliable one-case report that could be unreliable and not a proven treatment for all cases of serotonin syndrome.
E. I know, Lou, that Mirtazapine can cause serotonin syndrome.
F. I will take responsibility for any injury or death to the poster that I am in discussion here, Lou, as a result of following my claims here to the poster.
G. If my claim that Mirtazapine is a proven treatment for serotonin syndrome is false, then my claim that the site drugs.com give erroneous information is also false.
H. I am going to post here what I used to claim that the site drugs.com is to be ignored because it has erroneous information. Here are my citations that show this:
_____________________________________________
_______________________________________________
___________________________________________
Lou>
>
Posted by Robert_Burton_1621 on March 4, 2015, at 6:32:25
In reply to Lou's reply-hynuen-Robert_Burton_1621, posted by Lou Pilder on March 4, 2015, at 5:42:21
> > > Robert,
> You say that you do not follow my logic. I say to you that what you have posted here could result in the deaths or addictions or life-ruining conditions to other readers here and I am asking that we have an immediate discussion here.Lou, your assertion is misleading, inflammatory and unfair. Nothing I posted "could result in" (i.e., be relevantly causally related to) any of the terrible consequences that you imply in your statement would flow naturally from the post I made.
>This is all because the psychiatrist that operates this forum is allowing your claims here to be seen as supportive and I think otherwise,>The psychiatrist who operates this forum imposes as a condition of participation that no-one infers from the posts published here that medical advice is being supplied. The purpose of this forum is not in the online supply of clinical advice on which participants are intended to act but in describing, and thinking out-loud about, medication problems and *possible* medication strategies that participants might *think over*. No post here carries the express or implied intention or expectation that the content of any post should be acted upon *because* of any assumed expertise in the poster or because the reader has read the post here. Indeed, such expectations are very properly, and responsibly, expressly excluded by Dr Hsiung.
>and your claim that Mirtazapine is used to treat SS, and that the site drugs.com has erroneous information is what is in issue here.>
I never "claimed" that Mirtazapine "is used" (i.e., in the ordinary meaning of that aspect of the tense you have chosen to express my original comment in, habitually) to treat serotonin toxicity. I said that it "has been used" to treat such toxicity; and I say further than an authority argues persuasively that the serotonergic potency of mirtazapine is low to negligible in humans, a fact which the safe combination of venlafaxine and mirtazapine appears to bear out: see Human Psychopharmacology: Clinical and Experimental, (2006) 21, pp 117-25.
You produce accurately my claim, based in my experience, that the drug interaction section of drugs.com *has* erroneous information. I.e., that occassionally its information is erroneous in the level of detail it provides. Yet you then proceed, in one of your highly tendentiously phrased questions, to assert that I claimed that drugs.com is not "based on facts". I never claimed such a thing, nor did I ever claim to profess to a degree of knowledge of the entirety of drugs.com beyond my experience of it. My knowledge that it sometimes throws up erroneous information derives, in the instance to which I adverted, from its assertion that the combination of mirtazapine and venlafaxine poses a *major* risk of serotonin toxicity. Drugs.com also asserts that the combination of tranylcypromine and nortriptyline poses a *major* risk of serotonin syndrome, an assertion that is inconsistent with a clinical assessment of the pharmacological mechanisms of each drug. I would pose in reply to you the challenge to produce a citation which demonstrates this information to be accurate.
Most certainly did I not assert, or imply, that drugs.com contains information that is *always* or *mostly* erroneous. Not did I ever suggest that drugs.com should not be used or consulted. My point was that it is *better* to refer to specialist views rather than generic information as provided by drugs.com *exclusively*. Drugs.com may be a first port of call, but it shouldn't be the only one.
> If you could post answers to the following then by my responses I could address your claims here in what I think could save livesprevent life-ruining conditions and addictions.I do not propose to oblige you in this matter, given the tendentious and quite frankly deeply offensive way you have chosen to phrase your questions. Your purpose is not, clearly, fair-mindedly to elicit clarifications but to inflame prejudice. My answers are as provided above.
I note that you have had a habit of delivering yourself of outrageously unfair imputations against Dr. Hsiung. I do not propose to engage with you further given the nature of the imputations you have chosen to direct at myself.
It may also be as well to remind you that the primary purpose of this thread is to offer responses to fido; it is not meant for you to indulge in the riding of eccentric hobby-horses.
Posted by 10derheart on March 4, 2015, at 17:28:10
In reply to Lou's request-wrklez » Robert_Burton_1621, posted by Lou Pilder on March 3, 2015, at 19:54:06
Posted by Robert_Burton_1621 on March 4, 2015, at 19:57:37
In reply to Re: SSRI withdrawal symptoms really scare me! » fido, posted by Robert_Burton_1621 on March 2, 2015, at 17:51:52
> Mirtazapine has been used to treat serotonin syndrome.> I feel, from my perspective, that it is better to take into consideration well-evidenced information by people who have expertise in this particular area, than to rely reflexively on sites like drugs.com, but that is of course a matter for you and your doctors.
>Just a quick note to supply support for the statement that mirtazapine "has been used" to treat serotonin toxicity. This statement did not, of course, imply that mirtazapine is the optimal treatment for serotonin toxicity or that it is in any way habitually used to treat symptoms along the spectrum of serotonin toxicity. Its 5HT2 antagonism may be a plausible mechanism whereby it has been used to treat ST, though I suspect that given that the potency of this antagonism is not among the highest, then the extent to which it was reported effectively to treat ST may have been proportionate to the degree of severity of the symptoms which were treated.
Note that when I stated that it is erroneous to assert that the combination of mirtazapine with venlafaxine causes a *major* risk of serotonin toxicity, this applied only to any causal role of mirtazapine, not to that of venlafaxine. It also did not imply that mirtazapine has no potential for side-effects which are not related to serotonin-toxicity.
Here are citations to work arguing for, and perhaps demonstrating: (1) the negligible serotonergic effect of mirtazapine; (2) the unlikelihood that it can induce serotonin toxicity; and (3) the fact that it has been used as a treatment for serotonin toxicity or symptoms of serotonin-induced side-effects.
This is, to be sure, simply information I have sourced; my mentioning it carries no expert assessment of its definitiveness. That goes without saying. But it is possible to apply our own general critical intelligence to such information to assess whether it is likely to be worthy of consideration when we make any decisions about medication *with our doctor*. Drawing participants' attention to relevant information is intended to support the decision-making process they engage in with their clinicians. In my experience, some clinicians will not do any research themselves and patients are therefore, particularly if their conditions are long-standing and refactory, obliged through necessity to undertake research themselves. But given that most of us are not experts, the results of our research can mostly only be to expand the stock of information about which we are in a position to notify our clinicians. That can often be (though in those cases where clinicians are not receptive, usually is not) an empowering thing which *supports* and motivates our treatment under clinical supervision.
(1)
"A systematic review of the serotonergic effects of Mirtazapine: implications for its dual action status," Human Psychopharmacology: Clinical and Experimental (2006) 21, pp 117-25.
"Mirtazapine: not a dual action antidepressant?" Australian and New Zealand Journal of Psychiatry (2004) 38, pp 266-7.
"Mirtazapine enhances frontocortical dopaminergic and corticolimbic adrenergic, but not serotonergic, transmission by blockade of alpha2-adrenergic and serotonin2C receptors: a comparison with citalopram," Eur J Neurosci, (2000) 12(3), pp 1079 - 95.
(2)
"Mirtazapine: unable to induce serotonin toxicity?" Clinical Neuropharmacology, (2003) 26, pp 288-9.
"A Review of Serotonin Toxicity Data: Implications for the Mechanisms of Antidepressant Drug Action," Biological Psychiatry, (2006) 59, pp 1046-51.
"Adverse reactions to mirtazapine are unlikely to be serotonin toxicity," Clin. Neuropharmacology, (2003) 26, pp 287-288.
"Mirtazapine overdose is unlikely to cause major toxicity," Clin Toxicology(Phila), (2014) 52(1), pp 20-4.
(3)
"Mirtazapine as treatment for serotonin syndrome," Pharmacopsychiatry, (1996) 29(2), 81.
An authority refers to the above case study as "unsurprising, as [mirtazapine] is a 5-HT2A antagonist. Indeed, there is substantial evidence that 5-HT2A antagonists are effective treatments for [serotonin toxicity]": see Human Psychopharmacology: Clinical & Experimental, (2006) 21, pp 117-25, at p 122. The study is also referred to without criticism in Clinical Neuropharmacology (2003) 26(6), pp 288-9 at p 288.
"Mirtazapine abolishes hyperthermia in an animal model of serotonin syndrome," Neuroscience Letters, (2010) 482(3), 216-9.
"The effects of mirtazapine and fluoxetine on hyperthermia induced by 3,4-methylenedioxymethamphetamine (MDMA) in rats," Neuroscience Letters, (2011) 499(1), pp 24-7.
Considers mianserin: "Role of 5-HT(2) receptors in the tryptamine-induced 5-HT syndrome in rats," Behavioural Pharmacology (2002) 13(4), pp 313-8.
Considers mianserin: "Functional subsensitivity of 5-HT2A and 5-HT2C receptors mediating hyperthermia following acute and chronic treatment with 5-HT2A/2C receptor antagonists," Psychopharmacology, (1997) 130(2), pp 144-51.
5-HT2A antagonists: "Potent serotonin (5-HT)(2A) receptor antagonists completely prevent the development of hyperthermia in an animal model of the 5-HT syndrome," Brain Research, (2001) 890(1), pp 23-31.
Posted by fido on March 6, 2015, at 18:13:37
In reply to Re: SSRI withdrawal symptoms really scare me! » fido, posted by Robert_Burton_1621 on March 2, 2015, at 17:51:52
Since I'm on strattera right now I might try adding a SSRI to it and then see what happens. But even if this combo worked then I couldnt really tell wether it's the SSRI or strattera or both in combination which work.
So far I only know that lexapro 20mg for several months definitely didn't work for me at all. But it could be different with another SSRI.
But prozac and fluvoxamine are no options cause of interactions. This means only zoloft is left, and maybe brintellix but this is too new and who knows how safe it really is.It's really complicated somehow.
Even if SSRI + strattera helped with depression but not adhd then it would also suck cause I dont know if I could add ritalin to the mix. This could be too much.If SSRI + strattera should not work then I could switch to nortriptyline. But then I also dont know if I could add ritalin. I only know that TCA can interfere with Ritalin metabolism and raise blood levels which can also be risky.
It's really complicated when you have as many different issues as I have. And unless any antidepressant which I take makes a really huge difference in how I feel I may not even be able to tell if it works at all. Maybe some of the ADs which I have been on "worked" but they were simply so weak that they couldn't prevent me from still getting depressed. But then they're also not helpful at all.
Posted by Dr. Bob on March 14, 2015, at 22:27:39
In reply to Re: Lou's reply-hynuen-Robert_Burton_1621 » Lou Pilder, posted by Robert_Burton_1621 on March 4, 2015, at 6:32:25
> > I say to you that what you have posted here could result in the deaths or addictions or life-ruining conditions to other readers here
I'd like to redirect discussion of possibly life-ruining conditions to a different thread:
http://www.dr-bob.org/babble/20150223/msgs/1077523.html
Thanks,
Bob
This is the end of the thread.
Psycho-Babble Medication | Extras | FAQ
Dr. Bob is Robert Hsiung, MD,
bob@dr-bob.org
Script revised: February 4, 2008
URL: http://www.dr-bob.org/cgi-bin/pb/mget.pl
Copyright 2006-17 Robert Hsiung.
Owned and operated by Dr. Bob LLC and not the University of Chicago.