Citalopram 10mg > 20mg

[panic_down_under]

I've seen on other threads that it's relatively common to experience some symptoms when increasing the dose and I think I'm pretty sensitised at the moment anyway.

Unfortunately, heightened side-effects and raised anxiety levels often occur when increasing the dose. These usually resolve within a couple of weeks, but it may take longer for the higher dose to produce a positive outcome. Sadly, ADs are not a quick fix.

[LilyPad1991]

Unfortunately, heightened side-effects and raised anxiety levels often occur when increasing the dose. These usually resolve within a couple of weeks, but it may take longer for the higher dose to produce a positive outcome. Sadly, ADs are not a quick fix.

Hi again Panic Down Under.

Hope you’re doing ok. I’m having some issues with sleep: basically I can get to sleep for a couple of hours but then from the early hours until it’s time to get up, I’m getting adrenaline rushes that wake me up, one after another. It’s weird because I’m both tired and full of adrenaline. Is this part of the side effects of dose increase do you think? It’s awful.

Any insights welcome. I did wonder if maybe taking propranolol would help during these early weeks of 60mg of duloxetine?

I’m so worried duloxetine isn’t going to work for me anymore… But at the same time, I feel like the fact I’ve had side effects shows my body is ‘acknowledging’ the drug???

[panic_down_under]

I'm having some issues with sleep: basically I can get to sleep for a couple of hours but then from the early hours until it's time to get up, I'm getting adrenaline rushes that wake me up, one after another. It's weird because I'm both tired and full of adrenaline. Is this part of the side effects of dose increase do you think? It's awful.

It could be the dose increase, or it might just be anxiety, albeit maybe exacerbated by the AD.

I did wonder if maybe taking propranolol would help during these early weeks of 60mg of duloxetine?

Propranolol is definitely worth talking to your GP about. Not only should it block most of the adrenaline surge, it should also aid sleep.

I'm so worried duloxetine isn't going to work for me anymore

Bridges, crossing thereof! Try not to ruminating over things you can't control and which probably won't happen anyway. Diversion whenever the mind begins to wander into negativity works. A positive outlook won't improve the odds of a med working, but it can make the wait for it to kick-in more bearable.

But at the same time, I feel like the fact I've had side effects shows my body is 'acknowledging' the drug???

While my impression is that those who have significant side-effects are a little more likely to get a positive result from their AD than those who have no or only mild symptoms, the margin isn't that much, unfortunately.

[LilyPad1991]

It could be the dose increase, or it might just be anxiety, albeit maybe exacerbated by the AD.



Propranolol is definitely worth talking to your GP about. Not only should it block most of the adrenaline surge, it should also aid sleep.



Bridges, crossing thereof! Try not to ruminating over things you can't control and which probably won't happen anyway. Diversion whenever the mind begins to wander into negativity works. A positive outlook won't improve the odds of a med working, but it can make the wait for it to kick-in more bearable.



While my impression is that those who have significant side-effects are a little more likely to get a positive result from their AD than those who have no or only mild symptoms, the margin isn't that much, unfortunately.

Thank you so much for your reply and your kind words. I really am struggling. I think I had a rather unrealistic expectation of how quickly I would be ‘better’ again.

What are your thoughts on diazepam? I’ve been given 2mg tablets but I’m scared to use them. My doctor is very responsible and trustworthy but still, I’m scared. Oh the joys of anxiety!!

[panic_down_under]

What are your thoughts on diazepam? I've been given 2mg tablets but I'm scared to use them.

I'm not a benzophobe. I find much of what is claimed about them online is ridiculous and benzophobia has almost become a cult complete with gurus and inane rituals.

Firstly, you already have a dependence on diazepam and its metabolites, plus lorazepam (Ativan) and a number of other benzo like molecules. Benzodiazepine binding sites in the brain require benzodiazepines (BZDs) to activate them. There are no processes within the brain capable of producing them, and while there has been much speculation about how they might be synthesized in the body - gut flora was once thought to be the most likely source - nothing has ever been found despite much research. So it is now generally accepted that we derive all the BZDs we need from food as it has been known since the 1980s that plants make benzodiazepine compounds, and that they are also found in animal flesh and organs [1]. While the quantities we get from food are small, they are not insignificant. BZD can reach pharmaceutical levels and higher in patients with some liver diseases [2]. My guess is BZDs are a plant poison to which animal life, Homo sapiens included, has become so adapted to that we can no longer function without them.

Secondly, while coming off them can be difficult for some there are several ADs which are at least as difficult to quit yet most doctors and psychiatrists prescribe them unconcerned by this. Even quitting aspirin can be almost impossible for some. So why the hue and cry over BZDs?

That said, there are a couple of reasons why they should be taken sparely and not as primary anti-anxiety med. Firstly, the uncertainty of being able to get it prescribed in the future, and the possibility of being forced to wean off them quickly if/when your doctors decide they want you off them.

The second is they may significantly reduce the effectiveness of antidepressants by blocking hippocampal neurogenesis which is how ADs create the therapeutic response [3]. In light of these studies benzodiazepines use should probably be limited to a couple of weeks when first taking ADs just to ease the initial increase in anxiety levels, for a while after AD dose increases for the same reason and thereafter for occasional breakthrough anxiety.


References:

[1]
Muceniece R, Saleniece K, Krigere L, et al. (2008)
Potato (Solanum tuberosum) juice exerts an anticonvulsant effect in mice through binding to GABA receptors.
Planta Med. 2008 Apr;74(5):491-6. (Abstract)

Kavvadias D, Abou-Mandour AA, Czygan FC, et al (2000)
Identification of benzodiazepines in Artemisia dracunculus and Solanum tuberosum rationalizing their endogenous formation in plant tissue.
Biochem Biophys Res Commun Mar 5;269(1):290-5 (Abstract)

Sand P, Kavvadias D, Feineis D, et al. (2000)
"Naturally occurring benzodiazepines: current status of research and clinical implications."
Eur Arch Psychiatry Clin Neurosci vol 250(4) p 194-202 (Abstract)

Kotz U, (1991)
Occurrence of "natural" benzodiazepines.
Life Sci;48(3):209-15 (Abstract)

Unseld E, Krishna DR, Fischer C, et al (1989)
Detection of desmethyldiazepam and diazepam in brain of different species and plants.
Biochem Pharmacol Aug 1;38(15):2473-8 (Abstract)

Wildman J, U Ranalder U. (1988)
Presence of lorazepam in the blood plasma of drug free rats
Life Sci 43(15):1257-60 [Abstract]

Wildmann J. (1988)
Increase of natural benzodiazepines in wheat and potato during germination.
Biochem Biophys Res Commun. Dec 30;157(3):1436-43 (Abstract)

[2]
Baraldi M, Avallone R, Corsi L, et al (2000)
Endogenous benzodiazepines.
Therapie Jan-Feb;55(1):143-6 (Abstract)

Zeneroli ML, Venturini I, Stefanelli S, et al, (1997)
Antibacterial activity of rifaximin reduces the levels of benzodiazepine-like compounds in patients with liver cirrhosis.
Pharmacol Res , Jun;35(6):557-60 (Abstract)

[3]
Boldrini M, Butt TH, Santiago AN, et al. (2014)
Benzodiazepines and the potential trophic effect of antidepressants on dentate gyrus cells in mood disorders.
Int J Neuropsychopharmacol. Dec;17(12):1923-33 (Abstract | Full text)

Sun Y, Evans J, Russell B, et al (2013)
A benzodiazepine impairs the neurogenic and behavioural effects of fluoxetine in a rodent model of chronic stress.
Neuropharmacology. Sep;72:20-8 (Abstract)

Song J, Zhong C, Bonaguidi MA, et al (2012)
Neuronal circuitry mechanism regulating adult quiescent neural stem-cell fate decision.
Nature. Sep 6;489(7414):150-4 (Article | Study full text)

Wu X, Castren E. (2009)
Co-treatment with diazepam prevents the effects of fluoxetine on the proliferation and survival of hippocampal dentate granule cells.
Biol Psychiatry. Jul 1;66(1):5-8 (Abstract)

See also: the 'Ugly' part of Benzodiazepines: The Good, The Bad, and the Ugly

[LilyPad1991]

I'm not a benzophobe. I find much of what is claimed about them online is ridiculous and benzophobia has almost become a cult complete with gurus and inane rituals…

Thanks so much for all this info. After a hideous night of wave upon wave of adrenaline I finally took one last night. It took the edge off. I’m feeling very hopeless this morning, worried that I’ll never be myself again. Those 8 months of trying to taper off duloxetine felt like they were going so well but I’m concerned they were the biggest mistake of my life.


It’s day 16 back on 60mg and I feel horrendous.

[panic_down_under]

I'm concerned they were the biggest mistake of my life.

Very unlikely. But let's assume duloxetine doesn't work. It isn't the only AD, or necessarily the most effective. There is a very high probability that another AD will give a better result with fewer issues.

It's day 16 back on 60mg

You need to give it at least 6 weeks. It can take quite a while for these meds to kick-in and there are no shortcuts, unfortunately.

>and I feel horrendous

In what way?

[LilyPad1991]

Very unlikely. But let's assume duloxetine doesn't work. It isn't the only AD, or necessarily the most effective. There is a very high probability that another AD will give a better result with fewer issues.

I know you’re right but I just want this episode to be over. I’m so tired and scared. I don’t want to go through the trial of trying to find another medication and I’m scared of trying to come off duloxetine because it’s an absolute pig to stop taking.

You need to give it at least 6 weeks. It can take quite a while for these meds to kick-in and there are no shortcuts, unfortunately.

Thank you: I will stick with it, I know it’s early days and I know it’s common for SNRIs in particular to worsen anxiety before it gets better. I’m just impatient and it’s been a long time since I’ve had to deal with anxiety like this. I haven’t missed it! I wish I’d never even attempted to come off the drugs. I’ve potentially lost a good thing.

In what way?

I feel horrendous, especially in the morning, because of the rolling waves of adrenaline I’m having through the night. They’re exhausting and unpleasant and I really miss getting some decent sleep. When I’m tired I definitely ruminate more and ‘what if’ about everything. And the diazepam made me feel so bloody spaced out and it didn’t even stop the waves of adrenaline.

[panic_down_under]

I'm scared of trying to come off duloxetine because it's an absolute pig to stop taking.

The better way of dealing with it would be to do a slow cross taper to another AD.

I feel horrendous, especially in the morning, because of the rolling waves of adrenaline I'm having through the night. They're exhausting and unpleasant and I really miss getting some decent sleep. When I'm tired I definitely ruminate more and 'what if' about everything. And the diazepam made me feel so bloody spaced out and it didn't even stop the waves of adrenaline.

Did you tell your GP about the adrenaline surges? If so, I wonder why a beta-blocker wasn't prescribed? Blocking adrenaline surges is what they are best at.

[LilyPad1991]

The better way of dealing with it would be to do a slow cross taper to another AD.



Did you tell your GP about the adrenaline surges? If so, I wonder why a beta-blocker wasn't prescribed? Blocking adrenaline surges is what they are best at.

I’ve just come out of my appointment with my GP. She is a wonderful and supportive doctor and she had allotted me a long slot, I ended up having 45 minutes of her time to go through everything. We have a plan which does include propranolol and basically putting things in place to give me the chance to get some respite to allow duloxetine to work. She also addressed my ‘what iffing’ and catastrophising around duloxetine not working and explained what the next steps would be if that should become a problem although as she said (and you have said), there is no real evidence that that is a concern yet.

Thank you for getting back to me again and for being a voice of reason and support.