Mirtazapine and Paroxetine? OTC Sleep Meds affecting Paroxetine?

[WackoSirJacko]

Hi,

I've managed quite well since age 18 (now 40) on 20mg Paroxetine. Until a few bad things culminated into a mid life crisis Nov 16 which put me up to 40mg and gave me insomnia. It's cyclic so if I feel positive and latch onto some hope I'll sleep ok for a week or two then relapse. It's now come to the point where the relapses have just stolen the hope from me. This is after trying sleep restriction, CBT, slow release circadin melatonin (worked for 2 weeks but ended up making me depressed).

I went 4 days with no sleep and ended up in the crisis centre. They gave me some positive vibes and options and I slept again for a week. Now I've relapsed again and I've started trying OTC antihistamine sleeping tablets which worked OK but affect my mood the next day. Not necessarily tired, more up and down with a fuzzy head.

Anyway, I've basically coerced a Pscyh Doc to prescribe me 15mg Mirtazapine to go with my 40mg Seroxat/Paroxetine. My GP wouldn't prescribe it and the Psych was unwilling for the same reason of there being a chance of serotonin syndrome. It's not unheard of though and eventually the Psych doc relented. I just want to sleep though and get a lift on my mood to get to live my life again.


Has anyone took these 2 together? Does anyone else feel their SSRIs get sent out of kilter with Promethazine or Diphenhydramine sleeping tablets?

[panic_down_under]

My GP wouldn't prescribe it and the Psych was unwilling for the same reason of there being a chance of serotonin syndrome.

There is about as much chance of serotonin syndrome/toxicity (SS) as there is of you flying to the Moon by flapping your arms because mirtazapine is only an extremely weak serotonin reuptake inhibitor. To quote arguably the world's leading SS/ST expert, Dr Ken Gillman (http://scholar.google.com.au/citations?user=ea6KeD0AAAAJ&hl=en):

As I have pointed out before, drugs like bupropion and mirtazapine, that have no significant serotonergic activity, are no more likely to cause ST than is vitamin C

PK Gillman, 2010 PDF (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3550296/pdf/13181_2010_Article_84.pdf)

Moreover, mirtazapine is a moderate serotonin (https://www.ncbi.nlm.nih.gov/pubmed/17067560) 5-HT2a receptor antagonist (blocker). The recommend treatments (http://www.psychotropical.com/treatment-of-serotonin-toxicity) for serotonin syndrome are the 5-HT2a receptor antagonists cyproheptadine and chlorpromazine. 5-HT2a antagonists prevent the body temperature spike which does the damage in SS.

BTW-given you're being treated by a psychiatrist, ask for immediate-release trazodone (Desyrel) instead. Imho, it is a much better 'sleeping pill' as it has a very short half-life so the sedating effect usually doesn't continue into the next morning. At the higher end of the 25-100mg insomnia dose range it may also counter some SSRI side-effects, particularly sexual dysfunction. And no, it won't trigger SS either for the same reasons as mirtazapine. Trazodone is an even more potent 5-HT2a antagonist.


Does anyone else feel their SSRIs get sent out of kilter with Promethazine or Diphenhydramine sleeping tablets?

Paroxetine can increase the severity of promethazine side-effects which may be unsettling. Also promethazine is often combined with other drugs in a single pill and some of these other compounds can negatively interact with SSRIs. I have not heard of any issues with diphenhydramine, one of the compounds marketed as Benadryl, however, again there are many formulations under the brand, some of which contain compounds which affect serotonergic antidepressants.

[WackoSirJacko]

Thanks Panic

So even if I'm taking them together?

Interesting reading that Dr KG.

[panic_down_under]

So even if I'm taking them together?

Paroxetine and mirtazapine? Sure. After about a week of daily dosing plasma levels of both meds stabilize to a steady-state of around twice the peak from a single dose and then don't vary across 24 hours so it doesn't matter much whether you're taking them at the same time of day, or one in the morning, the other at night.


Interesting reading that Dr KG.

Yeah. Unfortunately, he is getting more and more frustrated by the amount of BS propagated about SS even by organisations such as the FDA, WHO, the UK MHRA, etc.