Alternating doses

[KingOfPanic]

Hi everyone!

I have been on citalopram (20mg) for nearly 4 years now and back in August I decided to try to taper off. The doctor told me to alternate from one day to the other between 20mg and 10mg. There didn't seem to be any problem at first, but I found myself increasingly struggling physically and now I've suffered a return to the crippling anxiety problems I thought I had conquered!

Could this be due to the constant changing between doses from day to day?

Thanks for any help :D

Jack

[panic_down_under]

back in August I decided to try to taper off. The doctor told me to alternate from one day to the other between 20mg and 10mg.

You've been doing this since August? Why so long? No tapering step needs to take 6 months.

You would probably have been okay if you'd dropped the dose to 10mg/day for a week, or two and then stopped. Some need to go slower, most don't.


Could this be due to the constant changing between doses from day to day?

Possibly because it was protracted, though not so much because of the changing dose as citalopram has a fairly long half-life which probably kept plasma levels fairly constant. That said, weaning off a med by alternating doses is still a stupid idea, imho.

The bigger problem was likely staying on a low dose for so long which may have increased the risk of the med pooping-out.


now I've suffered a return to the crippling anxiety problems I thought I had conquered!

Sadly, for some, e.g. me, these disorders are chronic conditions which wax and wane, sometimes with long remissions lasting months, even years, but which never completely go away.

[KingOfPanic]

You've been doing this since August? Why so long? No tapering step needs to take 6 months.

You would probably have been okay if you'd dropped the dose to 10mg/day for a week, or two and then stopped. Some need to go slower, most don't.



Possibly because it was protracted, though not so much because of the changing dose as citalopram has a fairly long half-life which probably kept plasma levels fairly constant. That said, weaning off a med by alternating doses is still a stupid idea, imho.

The bigger problem was likely staying on a low dose for so long which may have increased the risk of the med pooping-out.



Sadly, for some, e.g. me, these disorders are chronic conditions which wax and wane, sometimes with long remissions lasting months, even years, but which never completely go away.

Thanks for your response! I'm actually not sure why I was taking the alternating doses for so long, I guess I just assumed it was the same as dropping down to 15mg which it seems isn't the case.

Yes, I think I'm coming to terms with the idea that I may not have been cured forever haha

[panic_down_under]

I'm actually not sure why I was taking the alternating doses for so long, I guess I just assumed it was the same as dropping down to 15mg which it seems isn't the case.

Because of the long citalopram half-life you were effectively on only 15mg. Which may have been the problem. Antidepressants have no direct affect on anxiety (or depression) in the way benzodiazepines have on anxiety, or aspirin does with a headache. They work by stimulating the growth of new brain cells (http://www.americanscientist.org/issues/feature/depression-and-the-birth-and-death-of-brain-cells/99999) (neurogenesis) to replace cells killed, or prevented from growing by high brain stress hormone levels. The therapeutic response is produced by these new cells and the stronger interconnections they forge, not the meds directly. Taking sub therapeutic doses can interrupt or stop neurogenesis.

The second part of the problem is antidepressants seem to become progressively less effective every time they are stopped and restarted, often requiring higher doses to achieve the previous level of control. Two studies, Amsterdam JD (https://www.ncbi.nlm.nih.gov/pubmed/27805299), 2016 and Amsterdam JD, 2009 (http://www.karger.com/Article/FullText/226611) found the likelihood of an antidepressant working after each restart drops by between 19-25% (see also: Amsterdam JD (http://www.ncbi.nlm.nih.gov/pubmed/18694599), 2009; Leykin Y (http://www.ncbi.nlm.nih.gov/pubmed/17469884), 2007).

Taking sub therapeutic antidepressant doses for long periods of time may create a similar effect to stopping and restarting these meds as plasma levels fluctuate around the neurogenesis threshold. Even worse, it occurs at a higher frequency.