Can SSRI's prevent recovery and make OCD/Pure O worse?

[perry12]

Hi guys

I am currently on my third medication for OCD and each SSRI I have tried has done nothing for my intrusions.

I have become aware that each time I lower my dose on a med to prepare for trying a new one, my symptoms reduce, they don't disappear but it always seems better than a higher dose.

I then noticed that the majority of the recovery stories I have read and books from ex sufferers, all have a full recovery with no medical intervention.

I have also read that too much serotonin can cause the obsessions and not help at all.

I am beginning to wonder that with my therapy, tools and understanding of OCD is putting my mindset in a good place, along with exercise but then adding an SSRI to the mix is just too much serotonin. Surely as we improve, our serotonin levels increase naturally so at some point the medication is no longer needed?

Does anyone have any positive stories of medication helping them to fully recover or is it more a case of making it 'easier to deal with' ?

[Just A Person]

Honestly, I think it's always a case of making it 'easier to deal with'. If it were a cure, one could take the medication for a while, be cured and then stop taking it.

I think these medications are useful but mainly just bandages to stop the bleeding.

[snowghost57]

I agree, I think medication should be used as a bandage to stop the bleeding. Not to be used as a life long tool to cope. I didn't have OCD, however, I suffered from anxiety all of my life. After a series of stressful events in my life I fell apart. I mean, crying for two weeks, not being able to function fall apart. I cried all the way to the therapist. I was against medication. I tried it before and can't tolerate the side effects. I found this group and chatted and read threads.

I took Zoloft, also know as sertraline. I took 25mg for 20 days. I was in a cocoon, woke up as a zombie, sick on my stomach. I stuck it out. After I was up for a while and by the end of the day I felt more like myself. I was also on hydroxyzine for sleeping. I thought the hydroxyzine may be causing my fogginess and upset stomach. So I stopped that. My intrusive thoughts had stopped, my crying stopped. I was still ill at 4am in the morning, vivid dreams, not eating. So I weaned myself off the Zoloft, 1/4 tablet a day for 3 days and then none. I was scared of withdrawals as I read they are brutal.

I am now 8 days free of medication. This may sound strange, but my anxiety is gone. I don't have any obsessive thoughts or feeling the need to rush around in my life. Did the meds cure me? I don't know. I intend to talk to my doctor tomorrow about it.

Even while in my fog/cocoon from the meds, my brain learned how to push these negative thoughts out of my head. Will it do the same for OCD? I don't know. Every one reacts to medication differently. Good luck in your search for answers.

[MyNameIsTerry]

Hi perry,

Been a while.

I would suggest posting a thread like this on the general Meds board because we have a guy on there who knows a ton about meds (panic_down_under). I think he will be able to help you answer this question.

What stands out for me is that you see your symptoms reduce as the dose does. This makes me think the meds are too activating.

If you think about how overall anxiety levels seem to cause many of us to have more frequent & more intense OCD symptoms, it makes sense that if a med is causing too much adrenaline, the same occurs.

Have your doctors thought about adjusting downwards and monitoring to see if it helps?

[perry12]

Thanks for all of your responses.

I agree with your comment Terry about them being 'activating' .. I do think that is a possibility for me definitely. My therapist thinks for the symptoms etc I have been experiencing, her next course would be to work up to max dose Prozac. What worries me is from reading around is that Prozac is very activating.

I seem to be getting relief from a lower dose and when I overcame my GAD it was on Sertraline 50mg, 150mg did nothing good for me.

It is so hard when doctors and professionals think you need to be on a medication and that a higher dose is required to hit the OCD.

I think I will lower my current med down to the lowest possible dose and run that for a few weeks and if I get further relief, it may be a case of weaning off and continuing with last part of my therapy with no medical help. But then you always have the niggling thought of, perhaps I haven't found the right medication. If only these drugs were 'one size fits all' like paracetamol

[panic_down_under]

I am currently on my third medication for OCD and each SSRI I have tried has done nothing for my intrusions.

All SSRIs can theoretically treat OCD successfully, but in practice it doesn't always work out that way. In their defence, often the prescribed doses are inadequate for OCD. It is highly resistant to treatment, both with meds and therapy, so doses near the maximum are often required to get a positive response, but all too often antidepressants are abandoned as ineffective at low to medium doses.

The two antidepressants with the best OCD track record are the SSRI fluvoxamine (Luvox) and the TCA clomipramine (Anafranil), possibly because both also affect Sigma-1 receptors and transporters. Both seem to work equally well, however fluvoxamine interacts with many other medications and supplements which can complicate treatment of other illnesses, so I think clomipramine is the better long-term bet.


I have also read that too much serotonin can cause the obsessions and not help at all.

Serotonergic antidepressants can increase serotonin activity in the first few weeks, but the brain (and other serotonergic organs) respond to this within a few weeks by reducing serotonin (http://www.nomorepanic.co.uk/showthread.php?t=193671) synthesis and expression in areas of the brain associated with anxiety.


Surely as we improve, our serotonin levels increase naturally so at some point the medication is no longer needed?

Anxiety disorders (and depression) are not caused by a lack of serotonin, or any other neurotransmitter. The 'chemical imbalance' hypothesis was disproved almost as soon as it was proposed, though it still gets promoted by pharmaceutical companies and doctors as it is a simpler explanation than the real one.

Antidepressants 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.

BTW - a number of small scale studies have found the supplement N-acetyl-cysteine (NAC) can reduce OCD symptoms and also boost the effectiveness of antidepressants for OCD (Oliver G, 2015, PDF (http://ro.uow.edu.au/cgi/viewcontent.cgi?article=2918&context=sspapers)). There is a large scale international study currently underway to confirm this. NAC is generally a safe supplement with few side-effects so is worth a shot. It is used medically to protect the liver in cases of paracetamol/acetaminophen overdose and has many other uses (http://www.webmd.com/vitamins-supplements/ingredientmono-1018-n-acetyl%20cysteine.aspx?activeingredientid=1018). Doses of 1,800-3,000mg/day split across the three main daily meals seems to work (start with one dose per day of around 500-600mg and increase by by the same amount every 2-3 days to avoid triggering diarrhoea). NAC is best taken on an empty stomach about an hour before meals.

HOWEVER, be aware that a recent study (http://www.popsci.com.au/science/antioxidant-supplements-worsen-lung-tumors-study-finds) found NAC may increase the risk of lung cancer in smokers, or those with some specific lung diseases (note, it doesn't cause lung cancer, only maybe reduces the ability of the immune system to detect and destroy existing cancerous cells). The results have been the subject of much debate because there are many other studies showing NAC protects against lung cancer so it is probably not the final word on the subject. FWIW, I'm a lung cancer survivor and have take NAC for over 11 years because it is the best thing I've found for reducing fluid buildup in my remaining lung.

PS: as for all herbal remedies and supplements, check with your pharmacist or GP before taking NAC while on any prescription medication.

[perry12]

The two antidepressants with the best OCD track record are the SSRI fluvoxamine (Luvox) and the TCA clomipramine (Anafranil), possibly because both also affect Sigma-1 receptors and transporters. Both seem to work equally well, however fluvoxamine interacts with many other medications and supplements which can complicate treatment of other illnesses, so I think clomipramine is the better long-term bet.


Thanks for your response! The trouble I have is that my therapist and GP are both pointing at Prozac ideally or trying Escitalopram. I mentioned to both of them about Luvox/Anafranil before and they said they don't use them anymore and max dose SSRI is what they recommend.

I have been up to max dose Sertraline, Citalopram, Pregabalin. I kept at max dose on Sert/Citalopram for over 16 weeks and saw no improvement, possibly worse symptoms as when I reduced the drugs down to change, I always felt improved on the lower dose for some reason.

I am currently working down through Citalopram, sitting at 20mg and with all this conflicted advice I have no idea which direction to take.

Do you guys think Prozac would be a good option? How true is it that it is very activating (not good for anxiety) because it was Sertraline which brought on my OCD, I was put on Sertraline for GAD and the side effects of Sertraline was absolutely crazy, I have no idea how I stuck on it.

NAC sounds interesting, I will have a read! .. I have also tried Inositol and Magnesium Taurate

[panic_down_under]

The trouble I have is that my therapist and GP are both pointing at Prozac ideally or trying Escitalopram. I mentioned to both of them about Luvox/Anafranil before and they said they don't use them anymore and max dose SSRI is what they recommend.

...I kept at max dose on Sert/Citalopram for over 16 weeks and saw no improvement

with all this conflicted advice I have no idea which direction to take.

Requesting/demanding a referral to a psychiatrist is probably your best option. If maximum doses of 2 SSRIs have failed to produce a positive result, indeed may have made things worse, then the odds of a third being any better are pretty slim. Time to stop flogging dead horses, imho.

Unfortunately, too many doctors, even psychiatrists, are hung up on SSRIs being the holy grail of antidepressants. It's BS. Arguably they are less effective than SNRIs, TCAs and MAOIs. With the possible exception of citalopram and escitalopram, their only advantage is being safer in overdose. While this can be important for some patients, it alone isn't a reason for a blanket SSRIs preference. Just about every older psychiatrist I've asked who practiced through the MAOI, TCA, and SSRI/SNRI eras has nominated either clomipramine or the MAOI tranylcypromine (Parnate) as their first choice if they needed to take an antidepressant. None had a SSRI as their top pick.

[perry12]

Requesting/demanding a referral to a psychiatrist is probably your best option. If maximum doses of 2 SSRIs have failed to produce a positive result, indeed may have made things worse, then the odds of a third being any better are pretty slim. Time to stop flogging dead horses, imho.

Unfortunately, too many doctors, even psychiatrists, are hung up on SSRIs being the holy grail of antidepressants. It's BS. Arguably they are less effective than SNRIs, TCAs and MAOIs. With the possible exception of citalopram and escitalopram, their only advantage is being safer in overdose. While this can be important for some patients, it alone isn't a reason for a blanket SSRIs preference. Just about every older psychiatrist I've asked who practiced through the MAOI, TCA, and SSRI/SNRI eras has nominated either clomipramine or the MAOI tranylcypromine (Parnate) as their first choice if they needed to take an antidepressant. None had a SSRI as their top pick.

I appreciate your response and agree with what you are saying. I would really like to try Fluvoxamine but it does concern me that hardly anyone is on it, people hardly mention it on the forums and then my GP & therapist say they haven't used it for years. Yet with lots of searching, it seems to be number one choice for OCD, FDA approved, I am not sure if this is just for the USA though.

Do you know why there isn't many people on it? the people who seem to try it, have great relief from symptoms

Thanks for all your help

[MyNameIsTerry]

Perry,

This is what NICE have in their guidelines (this should help you out):

https://www.nice.org.uk/guidance/cg31/chapter/1-Guidance#steps-35-treatment-options-for-people-with-ocd-or-bdd

Choice of drug treatment
Selective serotonin reuptake inhibitors (SSRIs)
1.5.3.8 For adults with OCD, the initial pharmacological treatment should be one of the following SSRIs: fluoxetine, fluvoxamine, paroxetine, sertraline or citalopram[2].
1.5.3.9 For adults with BDD (including those with beliefs of delusional intensity), the initial pharmacological treatment should be fluoxetine[3] because there is more evidence for its effectiveness in BDD than there is for other SSRIs.
1.5.3.10 In the event that an adult with OCD or BDD develops marked and/or prolonged akathisia, restlessness or agitation while taking an SSRI, the use of the drug should be reviewed. If the patient prefers, the drug should be changed to a different SSRI.
1.5.3.11 Healthcare professionals should be aware of the increased risk of drug interactions when prescribing an SSRI to adults with OCD or BDD who are taking other medications.
1.5.3.12 For adults with OCD or BDD, if there has been no response to a full course of treatment with an SSRI, healthcare professionals should check that the patient has taken the drug regularly and in the prescribed dose and that there is no interference from alcohol or substance use.
1.5.3.13 For adults with OCD or BDD, if there has not been an adequate response to a standard dose of an SSRI, and there are no significant side effects after 4–6*weeks, a gradual increase in dose should be considered in line with the schedule suggested by the Summary of Product Characteristics.
1.5.3.14 For adults with OCD or BDD, the rate at which the dose of an SSRI should be increased should take into account therapeutic response, adverse effects and patient preference. Patients should be warned about, and monitored for, the emergence of side effects during dose increases.
1.5.3.15 If treatment for OCD or BDD with an SSRI is effective, it should be continued for at least 12*months to prevent relapse and allow for further improvements.
1.5.3.16 When an adult with OCD or BDD has taken an SSRI for 12*months after remission (symptoms are not clinically significant and the person is fully functioning for at least 12 weeks), healthcare professionals should review with the patient the need for continued treatment. This review should consider the severity and duration of the initial illness, the number of previous episodes, the presence of residual symptoms, and concurrent psychosocial difficulties.
1.5.3.17 If treatment for OCD or BDD with an SSRI is continued for an extended period beyond 12*months after remission (symptoms are not clinically significant and the person is fully functioning for at least 12 weeks), the need for continuation should be reviewed at regular intervals, agreed between the patient and the prescriber, and written in the notes.
1.5.3.18 For adults with OCD or BDD, to minimise discontinuation/withdrawal symptoms when reducing or stopping SSRIs, the dose should be tapered gradually over several weeks according to the person's need. The rate of reduction should take into account the starting dose, the drug half‑life and particular profiles of adverse effects.
1.5.3.19 Healthcare professionals should encourage adults with OCD or BDD who are discontinuing SSRI treatment to seek advice if they experience significant discontinuation/withdrawal symptoms.

Other drugs
1.5.3.20 The following drugs should not normally be used to treat OCD or BDD without comorbidity:
tricyclic antidepressants other than clomipramine
tricyclic‑related antidepressants
serotonin and noradrenaline re‑uptake inhibitors (SNRIs), including venlafaxine
monoamine oxidase inhibitors (MAOIs)
anxiolytics (except cautiously for short periods to counter the early activation of SSRIs).
1.5.3.21 Antipsychotics as a monotherapy should not normally be used for treating OCD.
1.5.3.22 Antipsychotics as a monotherapy should not normally be used for treating BDD (including beliefs of delusional intensity).

1.5.4 Poor response to initial treatment in adults

1.5.4.3 For adults with OCD or BDD, if there has not been an adequate response after 12*weeks of combined treatment with CBT (including ERP) and an SSRI, or there has been no response to an SSRI alone, or the patient has not engaged with CBT, a different SSRI or clomipramine should be offered.
1.5.4.4 Clomipramine should be considered in the treatment of adults with OCD or BDD after an adequate trial of at least one SSRI has been ineffective or poorly tolerated, if the patient prefers clomipramine or has had a previous good response to it.
1.5.4.5 For adults with OCD or BDD, if there has been no response to a full trial of at least one SSRI alone, a full trial of combined treatment with CBT (including ERP) and an SSRI, and a full trial of clomipramine alone, the patient should be referred to a multidisciplinary team with specific expertise in the treatment of OCD/BDD for assessment and further treatment planning.

1.5.4.7 Following multidisciplinary review, for adults with OCD if there has been no response to a full trial of at least one SSRI alone, a full trial of combined treatment with CBT (including ERP) and an SSRI, and a full trial of clomipramine alone, the following treatment options should also be considered (note, there is no evidence of the optimal sequence of the options listed below):
additional CBT (including ERP) or cognitive therapy
adding an antipsychotic to an SSRI or clomipramine
combining clomipramine and citalopram.
1.5.4.8 Following multidisciplinary review, for adults with BDD, if there has been no response to a full trial of at least one SSRI alone, a full trial of combined treatment with CBT (including ERP) and an SSRI, and a full trial of clomipramine alone, the following treatment options should also be considered (note, there is no evidence of the optimal sequence of the options listed below):
additional CBT or cognitive therapy by a different multidisciplinary team with expertise in BDD
adding buspirone[4] to an SSRI.
1.5.4.9 For adults with BDD, if there has been no response to treatment, or the patient is not receiving appropriate treatment, more intensive monitoring is needed because the risk of suicide is high in people with BDD.
1.5.4.10 Treatments such as combined antidepressants and antipsychotic augmentation should not be routinely initiated in primary care.

How to use clomipramine in adults
1.5.4.11 For adults with OCD or BDD who are at a significant risk of suicide, healthcare professionals should only prescribe small amounts of clomipramine at a time because of its toxicity in overdose[5]. The patient should be monitored regularly until the risk of suicide has subsided.
1.5.4.12 An electrocardiogram (ECG) should be carried out and a blood pressure measurement taken before prescribing clomipramine for adults with OCD or BDD at significant risk of cardiovascular disease.*
1.5.4.13 For adults with OCD or BDD, if there has not been an adequate response to the standard dose of clomipramine, and there are no significant side effects, a gradual increase in dose should be considered in line with the schedule suggested by the Summary of Product Characteristics.
1.5.4.14 For adults with OCD or BDD, treatment with clomipramine should be continued for at least 12 months if it appears to be effective and because there may be further improvement.
1.5.4.15 For adults with OCD or BDD, when discontinuing clomipramine, doses should be reduced gradually in order to minimise potential discontinuation/withdrawal symptoms.

So, onto the drug licencing...

CLOMIPRAMINE HYDROCHLORIDE

https://www.evidence.nhs.uk/formulary/bnf/current/4-central-nervous-system/43-antidepressant-drugs/431-tricyclic-and-related-antidepressant-drugs/tricyclic-antidepressants/clomipramine-hydrochloride

Indications
depressive illness, phobic and obsessional states; adjunctive treatment of cataplexy associated with narcolepsy

AND

Phobic and obsessional states, ADULT over 18 years, initially 25*mg daily (ELDERLY 10*mg daily) increased over 2 weeks to 100–150*mg daily; max. 250*mg daily

FLUVOXAMINE MALEATE

https://www.evidence.nhs.uk/formulary/bnf/current/4-central-nervous-system/43-antidepressant-drugs/433-selective-serotonin-re-uptake-inhibitors/fluvoxamine-maleate

dications
depressive illness, obsessive-compulsive disorder

Obsessive-compulsive disorder, initially 50*mg in the evening increased gradually if necessary after some weeks to max. 300*mg daily (over 150*mg in divided doses); usual maintenance dose 100–300*mg daily; CHILD over 8 years initially 25*mg daily increased if necessary in steps of 25*mg every 4–7 days to max. 200*mg daily (over 50*mg in 2 divided doses)

They still look licenced to me.

Is there anything you want to add to this that can further help, Ian? I'm guessing you know who our NICE? The panels that review & create this guidance are made up of experts in these fields and I've seen Dr Salkovskis state online that he has been involved in both for OCD, which is an area of his expertise and he is a big name in the NHS for mental health.

---------- Post added at 06:41 ---------- Previous post was at 06:30 ----------


Thanks for your response! The trouble I have is that my therapist and GP are both pointing at Prozac ideally or trying Escitalopram. I mentioned to both of them about Luvox/Anafranil before and they said they don't use them anymore and max dose SSRI is what they recommend.

I have been up to max dose Sertraline, Citalopram, Pregabalin. I kept at max dose on Sert/Citalopram for over 16 weeks and saw no improvement, possibly worse symptoms as when I reduced the drugs down to change, I always felt improved on the lower dose for some reason.

I am currently working down through Citalopram, sitting at 20mg and with all this conflicted advice I have no idea which direction to take.

Do you guys think Prozac would be a good option? How true is it that it is very activating (not good for anxiety) because it was Sertraline which brought on my OCD, I was put on Sertraline for GAD and the side effects of Sertraline was absolutely crazy, I have no idea how I stuck on it.

NAC sounds interesting, I will have a read! .. I have also tried Inositol and Magnesium Taurate

I don't know about the activating element, given it's more for depression (or was) then it might be but with it being such a slow burn of a med it might be more tolerable anyway until you get beyond it.

Ian mentioned earlier about this as a side affect but I think what we are talking about is a long term activation issue? I know mine has been going on for years and I can pinpoint it back to starting at the "N" dose of my SNRI. I never had these symptoms prior to this. I will be interested to know what Ian thinks but I've always thought it was due to the "N" interaction but at the same time I know anxiety sufferers who went through it on Ven that got past it. Mine took years to settle down through a lot of hard work, it's still there now though and flares up frequently. I never had diagnosable OCD until this happened. My OCD was fever pitch, and was for over a year and another 1-2 years to get it significantly reduced (Ian, I know you will say this med should have been changed but so you are aware, I knew little about anxiety or meds back then and my GP convinced me it was my escalating anxiety, not the med...I know better now and know how little he understands these meds from some questioning that showed his answers oppose what literature states)

Perry, weren't you on Ven? If so, when they say "we don't use X", remember what it says in the NICE guidance about use of SNRI's only where a co morbid diagnosis is made. :winks:

Also, if you have a co morbid diagnosis, it opens up further prescribing options according to NICE. :winks:

---------- Post added at 06:51 ---------- Previous post was at 06:41 ----------




BTW - a number of small scale studies have found the supplement N-acetyl-cysteine (NAC) can reduce OCD symptoms and also boost the effectiveness of antidepressants for OCD (Oliver G, 2015, PDF (http://ro.uow.edu.au/cgi/viewcontent.cgi?article=2918&context=sspapers)). There is a large scale international study currently underway to confirm this. NAC is generally a safe supplement with few side-effects so is worth a shot. It is used medically to protect the liver in cases of paracetamol/acetaminophen overdose and has many other uses (http://www.webmd.com/vitamins-supplements/ingredientmono-1018-n-acetyl%20cysteine.aspx?activeingredientid=1018). Doses of 1,800-3,000mg/day split across the three main daily meals seems to work (start with one dose per day of around 500-600mg and increase by by the same amount every 2-3 days to avoid triggering diarrhoea). NAC is best taken on an empty stomach about an hour before meals.

HOWEVER, be aware that a recent study (http://www.popsci.com.au/science/antioxidant-supplements-worsen-lung-tumors-study-finds) found NAC may increase the risk of lung cancer in smokers, or those with some specific lung diseases (note, it doesn't cause lung cancer, only maybe reduces the ability of the immune system to detect and destroy existing cancerous cells). The results have been the subject of much debate because there are many other studies showing NAC protects against lung cancer so it is probably not the final word on the subject. FWIW, I'm a lung cancer survivor and have take NAC for over 11 years because it is the best thing I've found for reducing fluid buildup in my remaining lung.

PS: as for all herbal remedies and supplements, check with your pharmacist or GP before taking NAC while on any prescription medication.

Ian,

They go to SSRI's first as that's the expert guidance given via NICE. To be honest, I don't think we would want our GP's playing around even more than they do now, they make enough mistakes with just SSRI/SNRI's. Once we get top psychiatrists, we are accessing Level 4 in NICE Stepped Care Model terms which takes us into any medication they wish. But having NICE guidelines is useful in forcing GP's to do things in a more structured way than allowing them to look at every possible med and make an ill informed decision based on little training and varying experience.

NAC is something I've come across before. I had read about it's use in Trichotillomania and how it had been successful. Something about specific Glutamate receptors in an area of the brain. It looks interesting but I hadn't realised it had been looked at in OCD. It still looks in need of research but the research in addiction treatment, and it's crossovers into obsessional behaviour in the brain, is certainly useful in seeing something possible now.

I have asthma so if it helps to control fluid build up, it may have it's uses for me too. Do you know anything about it's use in asthma sufferers, before I start looking? I want to give it a try in OCD terms mostly.

GP's are not knowledgeable when it comes to herbals but our pharmacists are normally very good. My mum always said that anything about a med, you ask a pharmacist if you want the best answer rather than a GP.

Sorry to hear you had LC but glad you have beaten it. There is a guy across the street from me who had a lung removed, I can't remember why and it was before he moved here, and he has been fine for well over a decade from what I've seen.

Another member, Pepperpot, her mother was diagnosed with stage IV LC last year so I'm sure she will find some strength from your posting about this. My GF's mother was diagnosed stage IV LC last year, but it wasn't meant to be...

---------- Post added at 08:05 ---------- Previous post was at 06:51 ----------

I meant to attach this link:

https://examine.com/supplements/n-acetylcysteine/

I find this site is useful with it including study info.

[perry12]

Thanks for the extensive response. I am 'diagnosed' as having GAD & OCD, so I should imagine with what you have said, I should be able to push for pretty much any medication within reason if Zoloft and Citalopram haven't really done a lot.

My mum is on Ven for MDD and does really well on it. My sister who also suffers with MDD, tried Ven but it didn't agree with her at all. After seeing the side effects it took on my sister, I really don't want to go there! she is now stable on 100mg Zoloft, which does nothing for me.

I suppose that really does show to me how different medications work for different conditions. Life is a pain in the side when your immediate family find relief from medications and your anxiety which was brought on by their actions is taking more to control! but that is a story for another day its just funny how the world works!

It did make me think if one reason why Fluvoxamine had stopped being prescribed was due to the cost, so I did a little research and found this document from Newcastle NHS, cost comparison chart October 2016
http://gmmmg.nhs.uk/docs/cost_comparison_charts.pdf

1 year treatment on Fluvoxamine - £304.79
1 year treatment on Citalopram - £11.18
1 year treatment on Sertraline £15.99

Would you guys say Fluvoxamine has any more side effects/interactions than say Sertraline/Citalopram? if so, where is best that I read about this.

Thank you.