PDA

View Full Version : Starting quetiapine



Dying_Swan
31-08-19, 08:12
Hi folks.

My psychiatrist decided yesterday to switch me from mirtazapine to quetiapine. I'm also on 225mg venlafaxine. I started mirtazapine in June and it has been amazing for sleep, but first dose of quetiapine has kept me up all night. I'm quite concerned by this, and also about weight gain. I put on a couple of pounds on mirtazapine and psych says quetiapine won't be any worse. I'd be grateful for any insight or experiences. I've been on some form of antidepressant since 2005 but antipsychotics are a new one for me and I'm apprehensive.

Thanks :)

Dying_Swan
31-08-19, 08:15
Sorry I should add dose of quetiapine - starting on 25mg, to increase to 100mg over 4 weeks

panic_down_under
31-08-19, 12:34
I've been on some form of antidepressant since 2005 but antipsychotics are a new one for me and I'm apprehensive.

Don't get too hung up on labels, they can be pretty meaningless with some being more about marketing than descriptive.

There's not that much difference between mirtazapine and quetiapine. They hit the same receptors, though the ratios are a little different and quetiapine is less potent with 50mg quetiapine being roughly equal to 7.5mg mirtazapine.

Has quetiapine being prescribed to augment venlafaxine because it isn't effective even at 225mg, or to replace mirtazapine for sleep?

Dying_Swan
31-08-19, 17:09
Thanks so much for replying, I was hoping you'd see this. I think it's mainly to augment ven but also to help with sleep. I got myself into a bit of a stew and emailed the psych who has come back and said to take it again tonight but with mirtazapine too, though he didn't say how much mirt or for how long. Yesterday he said he didn't want me on all 3 as it would be harder to keep track of what's working, but I guess my panicked email changed his mind

panic_down_under
31-08-19, 23:35
I think it's mainly to augment ven but also to help with sleep.

I'm guessing it more about augmenting venlafaxine. How effective is it? Close to having you back to 'normal', or falling well short and how long have you been on 225mg/day?

Dying_Swan
01-09-19, 10:51
I've been on 225 ven for about 2 months, and just 2 days on 25mg quetiapine. I'm not sure how effective it's been. I felt good after the ven was increased at first and mirtazapine was added, but the initial peak seemed to tail off after a week or so and I started to have some real ups and downs. That was partially stabilised by increasing mirt to 15mg but didn't help enough I guess. Last night I took ven, mirt and quetiapine and finally got a few hours sleep, but was still awake for longer than I'd have liked. Early days but so far, I'm not convinced quetiapine is going to help. Thanks so much for your help.

panic_down_under
01-09-19, 13:07
I've been on 225 ven for about 2 months, and just 2 days on 25mg quetiapine. I'm not sure how effective it's been. I felt good after the ven was increased at first and mirtazapine was added, but the initial peak seemed to tail off after a week or so and I started to have some real ups and downs.

Then, imho, you and your doctor need to start thinking whether venlafaxine is worth continuing with. I don't see the point in taking a med which isn't effective on its own and then adding more and more drugs in the hope of finding the magic cocktail that will solve all your ills. Maybe if the primary med was 95% of the answer, but not if it's falling well short. The absolute maximum venlafaxine dose is 375mg so upping it a bit is an option, but there are some potential risks and based on what you've been prescribed lately it looks like your doctor doesn't want to go there. Understandable.

The way I see it you have two options, hang in there for another month in the hope the venlafaxine kicks-in, which is still possible, but becomes less likely with each passing day, or cutting your losses and switching to something else, perhaps just the quetiapine if it makes a significant difference.

Dying_Swan
01-09-19, 20:19
Thank you, that's really helpful. He's already said max dose of ven would be 300mg (though I've read 375mg as you say), but I don't get the sense he's keen to increase it any further, as he wanted me to change it entirely to mirtazapine initially (I resisted but agreed a small dose). Can I ask what the risks would be with higher doses of ven? We're now going to have a battle about mirtazapine because I want to stay on it for sleep. Increasing tonight to 50mg quetiapine on advice of mental health service. Thanks so much for all your help. You are so knowledgeable!

pulisa
01-09-19, 21:08
I'm sure you already know but ven is notoriously hard to come off if your psych decides to change to a different drug. I really hope the quetiapine helps you and makes a diffference. Adjusting to different doses and addition of new meds can be very stressful when it's hard to predict what will happen..if anything does of course.

My son is seeing a psychiatrist on Tuesday-he has been surviving on very little sleep for weeks-so I'll be very interested to hear how you get on with your new regime.

panic_down_under
02-09-19, 01:13
Can I ask what the risks would be with higher doses of ven?

Mild to moderate serotonin toxicity. The rule of thumb is that serotoninergic ADs reach their full potential once 80% of the serotonin transporters are blocked. Venlafaxine usually meets that goal at doses <=150mg, so the only point of taking more is to antagonise the noradrenaline/norepinephrine (NA) transporters which might be worthwhile if venlafaxine became a strong NA transporter blocker, but it is only a weak antagonist even at 300mg. Meanwhile, the extra serotonin activity can lower the seizure threshold and adversely affect the other serotonergic organs. There is also the difficult withdrawal issue pulisa has mentioned which can be more prolonged the higher the dose being weaned off, although may be of less concern if switching to another serotoninergic AD.

Instead of increasing the venlafaxine dose any further a better option, imho, would be to add a small dose of one of the NE reuptake inhibitors, either desipramine or nortriptyline, but I believe the NHS isn't keen on this and prefer adding mirtazapine, or quetiapine when SSRIs/SNRIs don't work adequately.

Dying_Swan
02-09-19, 20:05
Thank you both for your replies. Really helpful to know. I've been worrying mildly about serotonin levels with this current regime but hopefully it's ok. The thought of coming off ven terrifies me and I have heard its not nice. I'm not really keen to increase it further. Today has been ok, I've just felt very tired which I guess is to be expected. I've emailed the psych to say basically I don't want to stop mirt, but haven't heard back yet. I might drop it to 7.5mg but I'm not willing to stop it yet. Pulisa - would mirtazapine be an option for your son? I have found it amazing for sleep. I'll definitely keep you posted. Not too sure when I'll increase the quetiapine again, I might leave it a bit longer. Thank you again, and PDU, I will ask him about those drugs if this regime doesn't work out. I asked about trazodone a while ago after you mentioned it but at the time he preferred for me to have mirt, don't know why.

panic_down_under
02-09-19, 23:57
I asked about trazodone a while ago after you mentioned it but at the time he preferred for me to have mirt, don't know why.

In the U.S. and Australia trazodone is the preferred med for SSRI/SNRI induced insomnia, but mirtazapine seems to be the NHS choice. Imho, trazodone is the better of the two simply because it has a much shorter half-life which lessens any sedation carry over into the next day. It is also a pretty good antidepressant at high doses, however, it is only a very weak serotonin reuptake inhibitor so won't help with venlafaxine withdrawal.

Dying_Swan
03-09-19, 17:11
Thanks PDU. He said he uses trazodone often but for whatever reason preferred mirtazapine for me. The whole combo totally knocked me out last night and I slept for about 14 hours :ohmy: feeling rough today - nauseous, cold, light headed. Feels a bit like I've had half a bottle of vodka, though I haven't. Speaking of which, I'm not sure what to do about alcohol. The box says no alcohol at all, the psych just pointed out its a depressant but didn't exactly say none at all. I'm not planning on heavy drinking or anything but what would your thoughts be? It also says no grapefruit juice, but I can't see that being a problem! I'm not feeling enthusiastic about the next increase if this is how it makes you feel. The mental health people want me to take diazepam as needed but I'm feeling pretty wary of adding another CNS depressant into the cocktail. Sorry for waffling, I wasn't expecting to feel so yucky.

Dying_Swan
03-09-19, 18:03
Just had a callback from duty GP, who won't get involved in psych meds whilst there's a psychiatrist involved :shrug:

panic_down_under
04-09-19, 05:48
Speaking of which, I'm not sure what to do about alcohol. The box says no alcohol at all, the psych just pointed out its a depressant but didn't exactly say none at all. I'm not planning on heavy drinking or anything but what would your thoughts be?

Alcohol is problematic for two reasons. Firstly, it blocks the hippocampi neurogenesis mechanism (http://www.ncbi.nlm.nih.gov/pmc/articles/PMC60045) by which ADs work. Even moderate drinking can reduce (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4568748/) hippocampus neurogenesis by nearly half (see also: Morris SA (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2861155/), 2010; Crews FT (https://pubs.niaaa.nih.gov/publications/arh27-2/197-204.htm), 2003.

The second problem is that ADs and psych drugs can affect the impact alcohol has. Some days you might be able to drink a herd of alcoholic elephants under the table without raising a sweat, at other times half a pint of light ale may turn legs to rubber. One or two drinks *occasionally probably won't hurt, but be careful until you work out how the meds/alcohol combo affects you and don't drive even if you think you're okay.


* note: "occasionally" does not mean on every day which ends in a 'y'! ;)

Dying_Swan
04-09-19, 19:02
Thank you, that is helpful info. I guess it sounds like alcohol isn't going to be a great idea, though at some stage I might test out a small amount. Usually I find it hard to stop once I start so I should probably avoid it for a while. I'm also meant to be taking diazepam, possibly changing to lorazepam, though I'm nervous about the number of CNS depressants here. The psych isn't keen on benzos but the MHT are - although they were only very briefly involved. I've just emailed psych again as don't really know what I'm doing anymore. Really worried about hassling him but as the GP won't advise, I don't have much choice. I'm incredibly thankful to have your advice here. I definitely wouldn't drive with alcohol, don't worry.

pulisa
04-09-19, 19:24
Mixed messages are so unhelpful and confusing. Can't the psych manage your care without additional "help" from the MHT? Just so you have one point of contact re prescribing?

Dying_Swan
04-09-19, 21:03
Thank Pulisa. He mainly is but I had a big meltdown at the weekend and they got involved, albeit briefly. The psych is private, and although I emailed him with their recommendations, I didn't hear back. I guess I'm one of many patients. Turns out the GPs haven't had his letter so won't prescribe anything without it. I'm stressed out about that and that once they do get it, they'll stop mirtazapine. I don't know if it's normal to feel worse when starting quetiapine but I sure as hell ain't feeling better. Sorry to be so gloomy. I'm so tired of it all.

panic_down_under
05-09-19, 00:24
I'm also meant to be taking diazepam, possibly changing to lorazepam, though I'm nervous about the number of CNS depressants here. The psych isn't keen on benzos but the MHT are

Taking a benzodiazepine occasionally is probably okay, but they become counter productive when taken often because they also inhibit (https://www.nomorepanic.co.uk/showthread.php?229765-Lofepramine-anyone&p=1892820#post1892820) hippocampal neurogenesis, i.e. it's the same issue as alcohol, but maybe worse.


I don't know if it's normal to feel worse when starting quetiapine but I sure as hell ain't feeling better.

Unfortunately, most psych meds make things worse at the beginning. It's almost a feature, not a bug. :ohmy: So don't read too much into how you're feeling atm, it probably isn't telling you anything useful about the med in the longer term.

Dying_Swan
05-09-19, 00:50
Thank you so much. I really do hope this is temporary, and your post is reassuring. I once heard the term "agitated depression" and think this might be it. I think diazepam is kicking in now which helps a little bit. I'm assuming alcohol and diazepam isn't likely to be recommended :unsure: I have also noticed I have immediate release quetiapine and everything I've read says it should be XR for adjunctive treatment of depression. Do you think that matters?

panic_down_under
05-09-19, 07:09
I'm assuming alcohol and diazepam isn't likely to be recommended

No! Not only is their the issue of a additive impact on neurogenesis, but the combination is potentially fatal as both depress brain stem activity. The brain stem takes care of a lot of basic functions, including the breathing and gag reflexes. In large doses the combo can lead to asphyxiation during sleep. Gag reflex suppression increases the risk of choking on vomit, or inhaling it into the lungs.


I have also noticed I have immediate release quetiapine and everything I've read says it should be XR for adjunctive treatment of depression. Do you think that matters?

Quetiapine has a short half-life, around 6-7 hours, which makes it a better sleeping pill than mirtazapine because the sedation is less likely to continue into the next day. However, for depression, and especially anxiety, the trick is to maintain plasma levels as even as possible. Taking it in 2-3 split doses usually works well enough, but slow-release formulations are even better and only need to be taken once daily which increases compliance. Humans, being the ornery creatures we are, become progressively less interested in taking a med the more often we have to each day.

pulisa
05-09-19, 08:14
I'm so sorry that you are feeling so bad, DS. For what it's worth, I also have a diagnosis of "agitated depression". It's so frustrating when letters take ages to reach the right people which delay things and leave you in the lurch.

I'd say ring the psych's secretary and find out where that letter to the GP is? I always felt like a zombie on anti psychs-why can't the mirt be continued if it helped with sleep?

Dying_Swan
05-09-19, 20:04
Thanks both. I'll try to avoid the booze/diazepam combo then :D I've had the two together numerous times but not with quetiapine. I will ask about XR next time. I'm a little surprised he didn't prescribe that as he was very keen for my venlafaxine to be XR. Perhaps that explains my mood getting lower as the day goes on.

I had a call from the psych today who wants me to get up to 100mg quetiapine quickly, and it sounds like he's going to up it further at my next appointment, to 200-300mg. He thinks it should help me sleep but agreed I can stay on mirtazapine too if I need to, so I'll probably drop that to 7.5. He didn't say much about diazepam or lorazepam, just that they're for emergencies and I can take them if I need to. I'm really hoping the letter has got to the GP or I'll run out of quetiapine.

Ive felt pretty exhausted today and the lovely moments of euphoria I was getting before have gone for now, but I'm not currently feeling quite as awful as I did the last 2 nights so will try to get an earlier night I think.

Sorry for long rambling post. It helps me to get it out here.

Pulisa, I'm sorry to hear you go through this too. Can I ask how agitated depression makes you feel? I think he thought the mirt hasn't done much for my mood and that being on too many things at once makes it difficult to know what's working

pulisa
05-09-19, 20:48
I'm probably right at the other end of the "can't get out of bed" spectrum. There's no way I could tolerate a day doing nothing as I need to keep moving no matter how bad I feel. just to try to distract myself and get away from my thoughts.

I don't take meds but have done in the past. I have some diazepam for the really bad times but take it sparingly. It doesn't do much anyway. I need to function predictably for my family so have worked out my own coping mechanisms which help me get through the day and night.

I'm glad your psych got back to you and I hope that you can sleep tonight..

panic_down_under
06-09-19, 00:21
sounds like he's going to up it further at my next appointment, to 200-300mg

That is the usual dose range when augmenting an antidepressant. It may look like a lot, but it's a modest dose relative to the maximum 750mg for the immediate release, 800mg for XR formulations.

Dying_Swan
06-09-19, 21:44
Thanks guys. I guess I'll see how it goes at 100 when I get there, and brace myself for a further increase. Feeling a bit better today although still cold, and still managed to sleep with 7.5 mirtazapine. The letter has finally got to the GP too, so I should be ok and not run out. I looked up agitated depression and it sounds exactly like what I have sometimes been experiencing, though not all the time. The GP won't give me lorazepam without the psych requesting it, so I suppose I'll stick to diazepam for now. I agree Pulisa, it doesn't do a whole lot, but I think it takes the edge off. It must be very difficult for you trying to look after a family feeling this way, and I admire you enormously.

pulisa
07-09-19, 08:55
Oh don't admire me, DS!! I muddle through the best I can but I'm hardly a good advert for coping with all this!

I'm glad that your GP has got all the info needed to prescribe. Chasing up letters just adds to all the stress and angst. I hope you feel a bit more stable this weekend and reassured that your new meds regime will be a positive move and that you can get some sleep which always helps so much during the challenging times.

Dying_Swan
09-09-19, 20:56
Thank you Pulisa, and I still admire you! It's hard enough dealing with it when you don't have kids to think of, let alone when trying to run a family.

I increased up to 100mg last night. Had a busy weekend which left me exhausted, but I think was a helpful distraction. I'm going to stick at that dose now until next psych review, alongside 225 Ven and 7.5 mirtazapine. Apart from being tired and cold, I've not noticed any other major side effects. Anxiety ramping up a bit, and I miss the euphoria, but I guess the aim is stability. Definitely more stable than last weekend so hopefully that's a good sign.

Dying_Swan
10-09-19, 12:41
Panic down under, could I ask a quick question? I know you said quetiapine has a short half life of 6-7 hours. I'm just wondering how it can help depression if half of it is out of my system by the time I wake up? Is it supposed to do its job when I'm asleep? Sorry if it's a silly question, and thanks in advance.

panic_down_under
11-09-19, 08:51
I know you said quetiapine has a short half life of 6-7 hours. I'm just wondering how it can help depression if half of it is out of my system by the time I wake up? Is it supposed to do its job when I'm asleep? Sorry if it's a silly question,

The only silly questions are those that are never asked.

Quetiapine seems to work by enhancing the ability of antidepressants to grow new brain cells (neurogenesis) in the hippocampal regions of the brain. Its active metabolite norquetiapine is also a fairly potent noradrenaline, aka norepinephrine, reuptake inhibitor which may add to its effectiveness at higher doses.

As for the short half-life, norquetiapine has a similar half-life, but I don't know whether this actually lengthens the time the med remains effective as the NRI antidepressant impact is distinct from the parent drugs neurogenesis affect. I think they probably run in parallel rather than serially. Either way, with daily dosing plasma levels of both quetiapine and norquetiapine reach a *steady-state in about 2 days at which point their plasma levels will remain pretty much constant across 24 hours. But for a good therapeutic outcome immediate-release quetiapine should be taken 2-3 times a day. The XR formulation only needs to be taken once daily, preferably in the evening.


* as a rule of thumb it takes about 5 half-lives for a med's plasma levels to stabilize to a steady-state with regular dosing

Dying_Swan
12-09-19, 00:37
Thank you so much for that explanation. It is encouraging to hear about the noradrenaline impact. I'm going to ask about XR at my next appointment. My guess is that it's about cost. My first prescription was private and I looked up the prices before getting it - the XR was a lot more expensive. So far I'm doing ok. Euphoria still eludes me but I generally feel more stable, if a bit more anxious. Each increase has knocked me a bit, so I'm not sure what 200-300mg will be like, or how quickly it will be increased, but I'll cross that bridge when I come to it. Thank you again. It's a huge help to be able to ask all these things.

panic_down_under
12-09-19, 08:52
It is encouraging to hear about the noradrenaline impact.

I does mean you're effectively now on a fairly potent SNRI. Even at 300mg venlafaxine is only a weak NRI.


My first prescription was private and I looked up the prices before getting it - the XR was a lot more expensive

Even when factoring in only having to take one pill per day instead of 2-3?

Dying_Swan
16-09-19, 20:45
Thanks PDU. I think I'm doing ok on it, so hopefully potent is working! From what I remember, XL was around 6 times more expensive than immediate release, but I'm back to the psych tomorrow so I will ask him.

Dying_Swan
17-09-19, 18:55
I've just had psych review. I had to tell him about the awful meltdown a few weeks ago, but that things seem a bit better now. He said he thinks I seem calmer, which is good, although he wants me to improve a bit more yet. I told him I'm no longer getting euphoric moments which is a shame, but I think he sees that as a good sign. He wasn't keen on me having lorazepam and thinks diazepam is a better bet for me. About XR quetiapine, he said as the immediate release has been ok for me, I can stick with it, but I have to increase to 150mg tonight and up to 200 by the weekend. I'm staying on 225 ven/7.5 mirtazapine. He's going to request an update from my CBT therapist (as I said I've not been finding it helpful lately) and will ask my GP to refer me for an assessment on the NHS, I guess to see if there's any other help. I wish that had happened a couple of weeks ago really, as it feels a bit belated now. Follow up in a couple of weeks. Bracing myself for the next increases.

pulisa
18-09-19, 20:08
I never understand why dosage is increased if you feel more settled and calmer on what you are on now but there's obviously a valid reason.

You may be in for a long wait for NHS therapy but that's based on waiting times in my area (South East).

Fingers crossed for a smooth transition upwards..I'm glad things are a little better after your recent awful time.

Dying_Swan
19-09-19, 01:14
Thanks Pulisa. I'm not holding my breath about the NHS route, but for whatever reason he seems to think it's a good idea. I think he thinks I can make some more improvement with a higher dose. That would be nice, but I'm a bit disappointed that I no longer seem to be able to feel "high" either. I guess it's a price worth paying to hopefully avoid the extreme lows and agitation, but I do miss those moments!

pulisa
19-09-19, 08:15
Can I ask what feeling "high" feels like to you? Do you feel like you haven't got a care in the world and can take on anything?

Dying_Swan
19-09-19, 13:08
Can I ask what feeling "high" feels like to you? Do you feel like you haven't got a care in the world and can take on anything?

Yes, pretty much. It's hard to explain but things like music sounds amazing, the louder the better. Things feel fun, almost thrilling, but there is a slightly frantic energy and impatient feeling to it as well. It doesn't last more than a few hours though, and it's gone since starting quetiapine. I was slightly concerned about hypomania but I don't think it lasts long enough. My therapist said maybe it's not euphoria, just normality, which feels like euphoria as I'm so accustomed to being down, but I'm not convinced. Do you get this too?

pulisa
19-09-19, 13:31
Yes but rarely and to me it's a break from agitation. I've never thought of it as euphoria though-just feeling a bit more "normal" and able to enjoy a bit of a positive adrenaline buzz. A bit of escapism too, I suppose. I've never thought of medicalising it. I don't see what is wrong with feeling a bit more "alive" and engaged?

Dying_Swan
19-09-19, 14:40
I agree and was enjoying those moments when they came along, like some much needed relief. Now I'm chasing it and can't get to it. I said to the psych that I hoped next time I'd be bouncing off the walls (perhaps a poor choice of words), but he said no, let's just aim for calm. Calm is well and good but fun is important too.

Dying_Swan
19-09-19, 20:22
Sorry, me again. Does anyone know if it's normal to have increased agitation with quetiapine when increasing the dose? I've not had this level of climbing the walls for a couple of weeks, I guess when I last increased. 2 days now on 150mg, might up to 200mg tonight or tomorrow. Tried everything I can think of: diazepam, brisk walk, distraction, music. Psych wants me to read a book but concentration has gone out of the window. The therapist said to call Samaritans for these times, but I don't particularly want to talk about it, I just want to be anaesthetised. Is this the drug? The depression? Tried to tell a relative but she didn't understand it's not panic. It's being unable to sit still, literally tearing your hair out, and feels like you can't stand to be in your own skin. If it's the quetiapine increase I can hopefully get through it. Pulisa, does this sound like what you get? Can I ask what you find helpful? Sorry for rambling. I don't know what else to do.

pulisa
19-09-19, 20:37
Yes I am very used to living like this, DS. I suspect that you are worried about how the increase will affect you and your anxiety has ramped up as a result?

But of course I don't know about the quetiapine increase-I'm just used to tolerating and accepting agitation for what it is-an unbearable feeling of not being able to concentrate or keep still or think straight. Can you ring the MH crisis line for some advice if you can't bear it? The increase may be significant which will help you to cope with it?

pulisa
19-09-19, 20:40
Just don't google-call 111 if you can't access a MH helpline because maybe just talking to someone will help bring down the agitation a bit?

Dying_Swan
19-09-19, 21:30
Thanks so much for replying. I think diazepam has taken the edge off, so I'm going to try to eat something and then see. If it carries on I'll call them. I haven't really been worried about the increase as I knew it was coming, though I did Google and seems it can be a side effect. Bloody hell though. What an awful feeling. I'm so sorry you have to deal with this on a regular basis. It's an intolerable feeling and I really hope it eases off for you.

pulisa
20-09-19, 08:15
Diazepam does take the edge off but I don't tend to use it now. I'm very used to feeling like this.

I hope you managed to get some sleep and that today will be a calmer and better day. It certainly gives a new meaning to "anxiety", doesn't it?!!

Dying_Swan
20-09-19, 13:45
My goodness, doesn't it just?! It is a great help to me to know someone else understands, but I really am sorry to know you suffer with it. It is amongst the worst feelings I know. The relative I spoke to wants me to go to some mindfulness class with her, but if I'm in that state I can't imagine anything less likely :wacko: I stayed at 150mg last night and did manage to sleep, so I guess I'll increase again tonight. Thanks so much for your support. I'm so grateful.

pulisa
20-09-19, 18:07
There are some areas where mindfulness just doesn't reach!!:D Even the psychologists admit this. A general anaesthetic would do the trick though or a powerful stun gun but not terribly practical and not available on prescription!!:D Glad that you feel a bit better-it is an unbearable feeling.

Dying_Swan
21-09-19, 13:39
Thanks Pulisa. You're totally right. I've had some advice to make an "emergency box" of stuff to stimulate the senses, like a blanket, something that smells strong, tastes strong etc. Must admit I think a stun gun or a general anaesthetic would be more helpful :roflmao:I'm now up to 200mg quetiapine. Here we go!

Dying_Swan
25-09-19, 20:28
Just an update. So far, not doing too badly. Agitation seems better on the whole, and I'm trying to keep myself a bit busier. I'm a bit under the weather physically which is annoying, but hopefully that'll clear up soon. Sleep isn't so good and I've had a couple of rubbish nights this week. I know quetiapine is supposed to be sedative but it totally isn't for me. Last night I felt like I needed to go running at 2am, so not ideal, but it's still early days. My GP was happy to give me some lorazepam despite the psych not being keen, though I'll keep that on standby just in case. Back to psych next week and wonder if he'll keep me at 200mg or if he'll increase.

Dying_Swan
27-09-19, 17:52
A couple of questions for PDU or anyone who might know. I am not sleeping so well and while I know quetiapine is meant to be sedative, I'm wondering if it's possible for it to do the opposite? I'm still on mirtazapine but it's not making me sleep like it used to.

Also, I'm a bit worried about leucopenia/neutropenia. I'm not traditionally a HA sufferer, but the patient leaflet says you should seek medical advice for sore throat, fever etc, which I've had for a week, but I wasn't worried as I knew I'd caught a cold when visiting a friend. But a week on, although some symptoms are improving, I'm still feeling quite rough, low grade fevers, cough etc. I spoke to GP on the phone and will have bloods next week, but I'm not sure how much of a risk it is, or whether I'm overreacting, or whether to cancel the bloods if it improves? Thanks so much in advance.

panic_down_under
28-09-19, 02:01
I am not sleeping so well and while I know quetiapine is meant to be sedative, I'm wondering if it's possible for it to do the opposite? I'm still on mirtazapine but it's not making me sleep like it used to.

Both quetiapine and mirtazapine affect much the same receptors to about the same degree which might be the issue as these meds are usually at their most sedating at the low end of their dose range, becoming less so as the dose increases.


I spoke to GP on the phone and will have bloods next week, but I'm not sure how much of a risk it is, or whether I'm overreacting, or whether to cancel the bloods if it improves?

Leucopenia and neutropenia are relatively common quetiapine side-effects affecting up to 10%, however, given you're only on a low dose your symptoms are more likely to stem from the cold. Even if you're feeling well next week the blood test would still be worth having, imho, even if only for peace of mind.

I never knock back any medical test doctors suggest even ones I'm sure are a waste of time because twice they have picked up other things which might not have been found until it was too late. Those of us with anxiety/depression tend to live longer than 'normies' and the main reason seems to be we see doctors more often and so are more likely to have problems discovered at an earlier, more easily treated stage. Being nutz can sometimes be an advantage.

Dying_Swan
28-09-19, 13:46
Thank you so, so much. Can't tell you how much it helps to have your advice. I don't know what I'll do about sleep, but that makes sense. Do you think trazodone would help? I don't know if that also acts on the same receptors?

I am relieved that you think it's more likely the cold and not neutropenia, but I'll go for the bloods just in case. My immune system has gone a bit up the creek this year, simultaneously letting me down whilst also attacking me, and I don't know how neutropenia etc would impact on all that. You're right that peace of mind is a good idea. Thank you again. You're a total star.

panic_down_under
29-09-19, 00:06
Do you think trazodone would help? I don't know if that also acts on the same receptors?

Mirtazapine and quetiapine mostly rely on blocking histamine H1 receptors to induce sleep. Trazodone is a much weaker H1 inhibitor and seems to rely mostly on serotonin 5-HT2a and alpha 1a receptors so it would definitely be worth a shot. Its use for sedation is well covered in Settimo L, Taylor D., 2017 (PDF (https://journals.sagepub.com/doi/pdf/10.1177/0269881117742101)) beginning toward the end of article page 99, the fourth page of the PDF.

Dying_Swan
29-09-19, 02:13
Thank you so much. I'll have a read and ask the psych again about it.

Dying_Swan
01-10-19, 18:55
Another psych review. Increasing to 300mg quetiapine, which I expected, but surprisingly reducing venlafaxine as he doesn't think it's helped. I said I can't tolerate once daily XR ven, so would take 75mg twice a day, but am thinking now I might try just the 150 in the morning. I'm a little worried as felt rubbish on 150 before, but maybe the quetiapine will take care of that. We agreed I'll go straight up to 300 and not do increments, as each increase seems to cause agitation. Also got the ok to try trazodone instead of mirtazapine for sleep. 50mg trazodone, which according to that article seems to be ok. I just have to wait for the letter to get to the GP to get them.

pulisa
01-10-19, 19:46
Do you feel satisfied with the review, DS? is there a plan to replace the ven?

Dying_Swan
01-10-19, 21:07
I think so, I get the impression he knows what he's doing, it's just frustrating that I don't seem to be improving as quickly as I'd like. I think the idea is that the extra quetiapine will replace the reduction in ven. Very much hoping I won't have withdrawal. Hope you are doing ok?

pulisa
02-10-19, 08:30
It must be a tough job being a psychiatrist (although certainly a lucrative one!) because individual response to drugs isn't predictable and it's all a bit trial and error.

It's good that you're happy with him and with his decisions because that all helps. I've seen some psychiatrists and have thought they have more issues than i have!!:D

Dying_Swan
03-10-19, 00:14
You're right about lucrative, especially when NHS mental health care is so underfunded and lacking and people are so desperate. I bet it's an interesting job, quite unlike other branches of medicine. So far I've survived 24 hours of 150mg venlafaxine and 300mg quetiapine, and like clockwork, heeeeeere's agitation! At least it's just the one increase this time. In a strange turn of events, I accidentally ate half a nitrofurantoin (antibiotic) capsule tonight, and am hoping there's no interaction. Think it's ok. I could ring 111 to check but fear I'd burst out laughing, or possibly crying.

A question. I take omeprazole and propranolol alongside venlafaxine for side effects, but if I'm taking it once a day I figure I don't need these twice a day. I've cut the omeprazole to once daily (20mg) but I have a feeling you have to be more careful with reducing propranolol. I have been on 20mg twice daily (40mg/day) and wondering if I can cut the evening 20mg? So that would be just 20mg in the morning. Or I could reduce and take 10mg PM. Sorry, I know I'm waffling again. Trying to keep calm and not doing a very good job :D

panic_down_under
03-10-19, 13:03
A question. I take omeprazole and propranolol alongside venlafaxine for side effects, but if I'm taking it once a day I figure I don't need these twice a day.

But venlafaxine XR is being released into your blood stream continually for ~24 hours. Omeprazole has a very short 1 hour half-life, though it's effect lasts longer than this and propranolol's is only 3-4 hours with its metabolite extending its effects by several more hours.


I've cut the omeprazole to once daily (20mg) but I have a feeling you have to be more careful with reducing propranolol. I have been on 20mg twice daily (40mg/day) and wondering if I can cut the evening 20mg? So that would be just 20mg in the morning. Or I could reduce and take 10mg PM.

I think you should discuss this with your GP first and definitely don't cut the propranolol PM dose completely until you've done so.

Dying_Swan
03-10-19, 17:37
Thank you PDU. I've kept up the evening 20mg propranolol as wasn't sure, so I will keep going with it until I see a GP. I had a feeling you had to be careful reducing it. The omeprazole has been for GI pain when taking venlafaxine, which has been ok, but maybe I'll just carry on with both for the time being. Thank you so much.

Dying_Swan
10-10-19, 14:02
Just an update. I am scared to say it for fear of jinxing it, but I think maybe the quetiapine is starting to help. I got through the agitation that seems to accompany an increase, and apart from brief moments of it, things feel calmer and I have more motivation. I'm even managing to read a book, which has been impossible for a long time. Sleep has been variable but I'm waiting for the pharmacy to get the trazodone, so hopefully that will help. Around an hour after taking quetiapine, my legs feel super heavy which is a bit odd, but a small price to pay. I'm writing this with everything crossed, but daring to feel just a little bit hopeful.

Jo79
10-10-19, 19:45
That’s great news :yesyes: I too have started to see some improvement, the last couple of days I’ve felt more able to rationalise my crazy thoughts and have felt more upbeat but today has been the best day so far, been getting out and doing normal things without my brain telling me I can’t cope. I’m the same, hoping I don’t jinx myself but everything is crossed :yahoo:

Dying_Swan
10-10-19, 21:50
Oh that's such great news Jo. I'm so pleased to hear you're on the up too! I know it's early days but the signs are good. Long may it continue :yesyes:

Dying_Swan
25-10-19, 23:41
I guess I jinxed it. Now on 400mg quetiapine and down to 75mg venlafaxine, and feeling pretty awful. Just taken lorazepam in the vague hope it might lift my mood. Still on trazodone for sleep but it doesn't help much. Apparently quetiapine can go up to 600mg but from what I've read, it should only be 300 max for depression. Heaven only knows what happens next. I think it's lowering my blood pressure too and not sure if I should be concerned.

Jo79
26-10-19, 08:17
Hi DS, wow, you got down to 75mg really quickly so no wonder you’re feeling awful! Are you coming off the ven completely or are they going to try something else to replace it?

I saw your other post regarding the CMHT and really pleased they changed their minds. I was thinking of you after my appointment and I did wonder why mental health services can be so erratic in their decisions. If you don’t mind me asking, what area are you in? I’m in Hampshire and my CMHT we’re pretty good. Now I’ve just got to wait to hear from them about seeing the new psychiatrist and MBCT sessions. The cpn I spoke to said she will try to get it sorted out asap but I won’t hold my breath, I expect it might take a while! My private psychiatrist said the CMHT will expect to take over my treatment from her which is fine with me, I don’t expect my insurance will want to pay out much longer anyway.

I really hope the ven withdrawal settles down soon, you’ve had a lot of changes to your meds over the last few weeks, I think you’re extremely brave for that :). I upped my quetiapine to 75mg last night as I’ve been having a few bad days this week. Thankfully I slept well and I’m not getting the increased anxiety (yet ��)

Dying_Swan
26-10-19, 14:54
Hi Jo. Thanks for your reply and kind words. I'm really glad you're doing ok and that you're going to get some proper support. My insurance has also stopped paying now, and I can see the logic of not having 2 psychs. I'm not sure whether I'm going to see the NHS one or not, so it's kind of left open with the private one for now. Maybe the rapid med changes have been more difficult than I'd realised. My guess is the (private) psych plans to get me off ven altogether, but I'm not sure, and don't know if it will be replaced with something else. I'm so glad you're going to have some psychological support too. I've been told I need a different type of therapy to CBT, but my goodness it's expensive! I'm planning to wait and see what the CPN says. I'll pm you where I'm at. Fingers crossed you continue to do well on 75 :)

Dying_Swan
28-10-19, 15:02
This quetiapine is doing strange things to my blood pressure. It seems to drop to 80-90/40-50 after taking it and I've had a couple of occasions where I can't stand up without my head spinning and ears ringing. Then it seems to go up to about 145/80 later on. I spoke with my GP about it and he's suggested I split the dose to morning and evening. Today I've taken 100mg at lunch time and will do 300 tonight, then 200mg am and 200mg pm tomorrow. I feel a bit in limbo at the moment with regards to psychiatrists, though I do trust my GP's advice. I also get a horrible sensation up my spine about an hour after taking quetiapine, like I have to move, but it's gone by morning. I'm going to switch back to mirtazapine from trazodone. Bracing myself for a sleepy day tomorrow. I'm just a little worried about the low BP as don't want to be keeling over.

Dying_Swan
31-10-19, 17:21
A few days into splitting the dose, and yuck, this is not nice. Still having low BP, and getting some dizziness with it. Years ago I had agoraphobia due to fear of fainting, and this is not helpful. I'm also self-medicating with methylprednisolone (long story, and *not* recommended) which probably isn't helping. I'm due to see the CPN from CMHT next week,but just phoned up and there doesn't seem to be any guarantee I'll see their psychiatrist, so I asked if I should book to see the private one, but was told to see what the CPN says. I've emailed the private one to ask, as totally unsure what to do. I hate feeling like such a nuisance but just seem to keep falling through the gaps between services. Back on mirtazapine which seems to help with sleep more than trazodone for me.

panic_down_under
31-10-19, 22:30
I'm also self-medicating with methylprednisolone (long story, and *not* recommended) which probably isn't helping.

It often significantly lowers heart rates (Bradycardia) which might be more responsible for the dizziness when getting up quickly than the low BP.

Dying_Swan
31-10-19, 23:19
It often significantly lowers heart rates (Bradycardia) which might be more responsible for the dizziness when getting up quickly than the low BP.

Methylpred? Thank you for that. I'm really hoping I'll not need it for much longer, and I'm using a bit of trial and error with the dosage. My BP seems to be sitting around 90/50, but I'm not sure whether to be worried about fainting or whether that'll be ok. I might start reducing my propranolol if it continues. Only on 40mg/day but I might bring it down a bit. I think tomorrow I might try 100mg quetiapine in the morning and 300 at night (currently 200 am and pm). If I'm going to have low BP I'd rather it's at night :wacko:

panic_down_under
01-11-19, 01:20
Methylpred?

Yes, on lower bpm.


I think tomorrow I might try 100mg quetiapine in the morning and 300 at night (currently 200 am and pm). If I'm going to have low BP I'd rather it's at night :wacko:

I'm not sure about that as the lower AM dose might be inadequate for its intended purpose.

That aside, interestingly, very recent advice for those taking BP meds is to take them at night, rather than in the morning as probably most do. Doing so significantly reduces the risk of heart attacks and ischaemic stroke, apparently.

Dying_Swan
01-11-19, 09:41
Thank you PDU. I hope I can stop the steroids soon, maybe even today. If not I'm going to try quartering the tablet to take the lowest dose possible. I'm wondering if they are also affecting my mood. Last night I was feeling awful, then I worry I'm "immune" to antidepressants and sedatives and that nothing will ever help. I was taking the whole 400mg quetiapine at night but my GP suggested splitting it to twice daily due to the low BP. I think though, it's just making it drop during the day too, so I was thinking to go back to the original 400 at night. As long as I'm asleep when it kicks in, it's fine, but if not I know all about it.

Interesting about BP meds. I'm not on propranolol for BP but assume it has an impact. A GP told me years ago not to take it at night as he said it keeps you awake, though it sounds like it's better to take it at night.

panic_down_under
01-11-19, 10:53
I think though, it's just making it drop during the day too, so I was thinking to go back to the original 400 at night. As long as I'm asleep when it kicks in

In slow-release form there shouldn't be a specific kick-in, just a pretty much level continuation, however, because the rate people metabolise meds can vary significantly there may be some who notice a drop off in apparent effectiveness before the next dose is due. The only certainty about psych meds is that there is no certainty. Everyone responds to them in their own unique way and even that can change from time to time. They are all very much 'interesting' meds in the Chinese sense of that word. :ohmy:


I'm not on propranolol for BP but assume it has an impact. A GP told me years ago not to take it at night as he said it keeps you awake, though it sounds like it's better to take it at night.

Seems so, though I don't know if beta-blockers (B-B) were part of the study which made the discovery. I think these days they aren't prescribed much for lowering blood pressure. Plus I'm not sure the GP was right. The B-Bs are generally tiring meds, not sedating in the way antihistamines are, but physically tiring, because of their impact on adrenaline. At least that was my experience when I was on one for a while years ago. Some afternoons I felt like I'd swum the Olympics 1,500 metres through a pool of treacle and felt exhausted. However, keeping the earlier caveat in mind, YMMV.

Dying_Swan
02-11-19, 09:59
Thank you PDU. I like what you said about there being no certainty. That's reassuring when I feel like I should be on cloud 9 with all this lot, but am absolutely not. Perhaps I will ask again about slow release. Last time I asked I was told there was no need as I wasn't having problems, but I think the BP and inner restlessness issues started for me at 300mg. I tried 100 yesterday morning and didn't feel dizzy thankfully, but I fell asleep last night without taking the 300, so not too hot today. I'm off the steroids now. My mood has been very low and I wonder if they were responsible.

Interesting that you found beta blockers tiring. I've been on them years, initially for hormone headaches and then increased due to venlafaxine-induced pounding heart/tachycardia. They have been very effective for both issues but I might try a reduction (slowly).

PDU - I want to thank you so much. You really are a huge help on these boards and I hope you know how much you are appreciated.

panic_down_under
02-11-19, 11:35
I'm off the steroids now. My mood has been very low and I wonder if they were responsible.

Very likely. Glucocorticoid steroids such as methylprednisolone frequently trigger (https://www.bmj.com/content/316/7127/244) depression and other psych disorders when taken for extended periods. They have much the same damaging (https://www.nature.com/articles/1395378) affect on the hippocampus as cortisol and alcohol. Fortunately, this tends to resolve fairly quickly once the steroids are stopped. ADs can be protective, or at least the SNRIs and SNRIs are, but for some reason the TCAs can sometimes make things worse. Not sure why.


Interesting that you found beta blockers tiring.

I wasn't on them long enough to find out whether tolerance can develop to this. I suspect not, but apparently some are worse than others. I don't recall which one I was on.


I want to thank you so much. You really are a huge help on these boards and I hope you know how much you are appreciated.

:blush: You're most welcome. I only know the little I do because others having been willing to share their knowledge and experiences over the years.

Dying_Swan
02-11-19, 17:14
Well, you know an awful lot! Scary about the steroids. I was only on them 3 days but perhaps that was enough to upset things. I've knocked alcohol on the head for now, but have taken a couple of doses of lorazepam over the past week in a desperate attempt to lift my mood. I'm considering raising my quetiapine dose. I tried emailing the psych for an appointment but heard nothing back, so feel a bit like I'm on my own with it now. I realise that's probably not advised and wouldn't recommend it to anyone else. Thank you PDU for making me feel a bit less alone with this.

panic_down_under
02-11-19, 23:07
I've knocked alcohol on the head for now, but have taken a couple of doses of lorazepam over the past week in a desperate attempt to lift my mood.

Total prohibition isn't required. The occasional drink or BZD dose won't matter. The problems start when occasional become most days. Also alcohol and psych meds can be a tricky as their combined affect may be unpredictable. Some days you might be able to easily drink a herd of alcoholic elephants under the table, on others half a pint could turn legs to rubber. Whatever you do don't drink and drive.

Dying_Swan
03-11-19, 00:04
I wouldn't drink and drive, no worries there. The problem I have with alcohol is once I start, I can't stop, and it has led to some hairy moments, especially when I'd taken diazepam too and scared myself a bit (lesson learnt). My impulse control isn't good at the moment. I've taken a double dose of lorazepam tonight, might have some more yet (within safe limits), but I'm not sure whether to up the quetiapine too. I've also found that having a drink after taking quetiapine means I can't stand up for feeling faint, so I assume it knocks my BP down further. Hopefully the benzos won't matter too much.

panic_down_under
03-11-19, 05:31
Hopefully the benzos won't matter too much.

Taking them for 2-3 days probably won't make difference, but 2-3 weeks is problematic. There are no hard and fast rules on this. It's all a trade off. Letting anxiety run unchecked can be just as bad. You do what you must to get through today so you can renew the battle tomorrow.

Dying_Swan
04-11-19, 09:33
Good advice. I don't take them daily, only if I really need them. Increasing my own dose of quetiapine was a bad idea and now I definitely wouldn't recommend it. Another lesson learned. Waiting to see the CMHT but don't know what they'll do with meds. The thought of switching again is just too much.

panic_down_under
04-11-19, 11:52
Waiting to see the CMHT but don't know what they'll do with meds. The thought of switching again is just too much.

Understood. But, otoh, there is no point on being on a med which doesn't work when you could be taking one that will. Unfortunately, finding the right one can be about the most frustrating thing you'll ever have to deal with as there are no real guidelines. You might as well pull the name of the next med to try out of a hat. Indeed, it might be a better option than taking the CMHT's choice as it won't be influenced by personal prejudice.

Dying_Swan
04-11-19, 18:55
That's a good point, thank you. I really thought the quetiapine was working for a bit, it's so disappointing. I've tried citalopram, fluoxetine and venlafaxine before. Honestly not sure anything will do much, but you never know.

panic_down_under
04-11-19, 21:52
I've tried citalopram, fluoxetine and venlafaxine before. Honestly not sure anything will do much, but you never know.

Then it might be time to bring in the big gun TCAs, amitriptyline, imipramine, or clomipramine with one of the latter two being my pick.

Dying_Swan
04-11-19, 22:52
Really? Are they effective? Side effects? Sounds scary, but then I was scared of antipsychotics a few weeks ago!

panic_down_under
05-11-19, 10:06
Really? Are they effective?

TCAs have been keeping me mostly anxiety free for most of the past 32 years, initially imipramine which was the gold standard panic AD before the SSRIs became available, since around 1997 by dosulepin which you won't be offered as it is being phased out in the UK. The SSRIs and SNRIs didn't become the preferred ADs because they were more effective, arguably they aren't, but because they were perceived to be safer in overdose. That has proven not to be true for all of them.


Side effects?

They often trigger fewer initial side-effects and can be easier to discontinue, but may have more ongoing side-effects, mostly nuisance ones such as dry-mouth and constipation which can usually be managed.


Sounds scary, but then I was scared of antipsychotics a few weeks ago!

TCAs are usually less problematic than psychotics.

Dying_Swan
05-11-19, 12:26
Thank you PDU. I took a small dose of amitriptyline years ago for sleep. It is encouraging to hear that you've got on well with them. I have read in the NICE guidelines that dosulepin shouldn't be prescribed. I'm seeing the CPN from the CMHT tomorrow, and I also managed to arrange a follow up with the private psych for later in the month. I decided to quit my CBT, rightly or wrongly, so for me it feels important to have at least some continuity with psychiatrists. I guess TCA's could be worth a try. I know there's MAOI's too, but they've never been mentioned to me.

Do you know anything about akathisia? About an hour after I take quetiapine, I get this horrible electricity-type feeling up my spine and absolutely have to move. I presume it's akathisia, and when I (stupidly) decided to increase my dose, it was horrendous. I'm unsure what to do about it. It does wear off after a few hours but the thought of it not wearing off is terrifying. I'm wondering if they just increase the quetiapine whether that will only get worse.

Jo79
05-11-19, 12:34
I was on Citalopram from 2011 which worked brilliantly but was changed to 25mg of amitriptyline 6 years ago when my partner and I were trying for a baby. My GP at the time said there was more evidence that it was safer during pregnancy as it’s an old drug. I had no problems at all and took it all the way though pregnancy until I had my son in 2015, got a new GP who put me back on the Citalopram as I started getting symptoms of PND. I reacted badly to the Citalopram and since then I have tried sertraline, escitalopram, mirtazapine and venlafaxine.

i suppose now I’m wondering...could the reason nothing is working well be because I have had a more powerful drug in my system in the past?

i’m now thinking I should ask my psychiatrist if I can change one of my drugs to a TCA, probably the mirtazapine and keep taking the venlafaxine and quetiapine for now. Is that a do-able combination? I’m reluctant to change the ven as I know it can be rough to get off.

or perhaps I should stop jumping the gun and give the quetiapine more of a chance :blush:

Dying_Swan
05-11-19, 13:10
Hey Jo. I'm really not sure so hopefully PDU will be able to advise you here. All I would say is that decreasing venlafaxine hasn't been nearly as bad as I'd expected, so I presume the quetiapine took care of that. I did get some withdrawal but it didn't last very long and wasn't too bad. I'm still on 75mg though, so not sure if stopping it completely would be worse. How much quetiapine are you on now?

Jo79
05-11-19, 13:51
I’m still on 75mg, I increased myself (slapped wrist) two weeks ago but will probably wait until I see the psychiatrist on Friday before increasing again. As PDU said, the usual dose for anxiety and depression is 150-300 so still room for improvement there.

I’ve just got no motivation and been feeling really irritable and aggressive lasting most of the weekend through to this morning but feeling a bit calmer this afternoon, Perhaps it’s because my son has gone back to school after half term, partner gone to work and I have the house to myself again :D

how long did it take you to get to 75mg of ven? Glad it didn’t cause too many problems and I suspect the quetiapine did help with that. Maybe any anxiety/depression you’re still feeling could just be withdrawal and may settle in time? Also good to know you still have a lot of options wrt TCA’s and there are other antipsychotics and mood stabilisers...my psychiatrist even suggested lamotrigine to me but I decided to give quetiapine a go first.

Dying_Swan
05-11-19, 15:46
Definitely wait to see the psychiatrist before increasing, and don't increase too much if you do it without their guidance (please don't). I've also felt pretty irritable and not sure if it's depression or the meds, or both. I guess it took about 4 weeks to get down from 225 to 75mg venlafaxine. I have wondered about mood stabilisers too and you're right that it's reassuring to think there are other things that can be tried. Sometimes it just feels like nothing will work which is disheartening.

panic_down_under
05-11-19, 22:00
iím now thinking I should ask my psychiatrist if I can change one of my drugs to a TCA, probably the mirtazapine and keep taking the venlafaxine and quetiapine for now. Is that a do-able combination?

Depends on the TCA as, unlike the SSRIs, they don't all do the same thing. The serotonergic biased TCAs, i.e. amitriptyline, imipramine and especially clomipramine would conflict with venlafaxine, but the noradrenergic TCAs, desipramine, nortriptyline and lofepramine could work.


Iím reluctant to change the ven as I know it can be rough to get off.

Perhaps, but taking a med that isn't working because it could, repeat could, it is not a certainty, be difficult to discontinue is unwise, imho, especially if it prevents getting on a med that could be the answer for you. Quitting venlafaxine directly can be problematic. Switching to the long half-life fluoxetine and weaning off it is usually easier.

Jo79
06-11-19, 08:05
Thanks PDU, will definitely chat to my psychiatrist before changing anything :) just reassuring to hear your views.

panic_down_under
06-11-19, 11:24
Should have added to my previous that it might be possible to switch from venlafaxine to a new med by cross-tapering which could negate much of any withdrawal response. It depends on what it chosen and how competent and confident your psychiatrist is. Don't let him/her just pick a med out of a hat (which admittedly in many circumstances is often as good a method as any other), but have these other factors considered too.

Dying_Swan
17-01-20, 15:47
Hello all. I have a couple of queries that I'm hoping PDU (or anyone who might know) will see.

Just to update - I'm still on 600mg quetiapine at night, am down to 37.5mg/day venlafaxine (supposed to stop soon but I'll probably halve it again), and was put back on trazodone, currently at 100mg, supposed to go up again to 150-200. I'm fully under NHS care now, and things have been difficult as we disagree about a number of things.

Anyway, due to various factors I keep missing my quetiapine, and I've noticed the main withdrawal symptom I get is hot and cold flushes, and a flushed face. It almost feels like I'm getting flu, though I checked my temperature during one of these episodes and it was normal. Does anyone know anything about that?

My other question is whether, when I've missed a dose, is it best to go straight back to 600mg at night, or to split it, or to say go back to eg 300 and increase it up? I've missed it for about 4 days now. I tried taking 200 yesterday afternoon but it knocked me out (so I missed the 400 later on), and I took 100 this morning to try to avoid the temperature issues, so I'll take 500 later I guess. Another issue I have though is akathisia, which comes on an hour or two after taking it if I'm not asleep, and it is one of the most horrible sensations ever. It seems the most I can tolerate in the morning is 100, or it plunges my BP and knocks me out. I haven't taken trazodone for days either. It isn't intentional, it's just how things have worked out.

Im sorry this is so long and probably doesn't make a lot of sense, but I'd be really grateful if anyone has any thoughts.

panic_down_under
17-01-20, 23:10
Anyway, due to various factors I keep missing my quetiapine, and I've noticed the main withdrawal symptom I get is hot and cold flushes, and a flushed face. It almost feels like I'm getting flu, though I checked my temperature during one of these episodes and it was normal. Does anyone know anything about that?

Flu like symptoms are fairly common withdrawal symptoms of many meds, not just antidepressants, anti psychotics and benzodiazepines. I don't know why this is.


My other question is whether, when I've missed a dose, is it best to go straight back to 600mg at night, or to split it, or to say go back to eg 300 and increase it up? I've missed it for about 4 days now.

Is the 600mg taken in an extended/slow-release, or immediate-release formulation?

My basic rule of thumb for meds generally is to take the missed dose asap if it is 12+ hours until the next scheduled dose, skipping it if <12 hours.

However, missing doses for 4 days is a different kettle of fish. I'd take 300mg for 2 nights and then back to 600mg, but this probably won't be side-effects free. I don't think they can be avoided no matter what you do. :sad: Skipping doses is fraught. Maybe set an alarm on your watch or phone as a reminder.


I haven't taken trazodone for days either. It isn't intentional, it's just how things have worked out.

How long have you been taking it and how long at 100mg if you started on a lower dose?

pulisa
18-01-20, 08:49
Do you have any faith in the new psychiatrist, DS? I can't comment about the choice of meds but I'm wondering whether they just make you feel worse.

Dying_Swan
18-01-20, 11:18
PDU- thank you so much. I've not been able to find any mention of these hot and cold flashes on anything about quetiapine withdrawal, but that's reassuring. I'm on 600mg immediate release, I took 100 yesterday morning and 500 last night, and luckily slept through any side effects. My sleep has been so messed up though, which is partly why I keep missing it (one night I'll crash out on the sofa for 15 hours, the next I'll be up all night with akathisia and agitation). Maybe slow release would be a better option. I asked about reducing it but they advised against it as I'm reducing ven.

I've been on 100mg trazodone for a week or so (missed doses aside), and started on 50. I'll probably go up to 150 tonight or tomorrow night, and I can go up to 200 if needed, although it doesn't seem to work for me.

Thank you Pulisa. I don't have much faith in this psychiatrist. I don't think he listens, and he changes his mind about things. I did like the previous one but am stuck with this one for now. I'm going to ask about another opinion. How is your son getting on?

pulisa
18-01-20, 20:50
You are within your rights to request to see another psychiatrist-just put it in writing to the Service Head of your CMHRS. I hate psychs who are ditherers-really doesn't give you confidence when you most need it because these drugs aren't smarties!

My son was hospitalised for nearly 3 weeks (NHS) but is home now on ven and risperidone. It has all been pretty horrendous just living in fear of what he will do next. He is starting EMDR therapy next week providing he can keep himself safe.

panic_down_under
18-01-20, 21:46
I've been on 100mg trazodone for a week or so (missed doses aside), and started on 50. I'll probably go up to 150 tonight or tomorrow night, and I can go up to 200 if needed, although it doesn't seem to work for me.

Have you been on trazodone before? If so what was the highest dose taken?

Dying_Swan
19-01-20, 15:38
Thank you both for your replies.

Pulisa, I am sorry things are still so difficult for you and your son. It must be nice to have him home, but must also be a worrying time for you. I hope the meds and the EMDR will be helpful. Thank you for your advice about psychs. I am seeing the CPN tomorrow so will ask. This psych announced in October there was nothing wrong with me (without meeting me), and then did a 180, and I'm struggling to understand how they can do that. I'll be keeping my fingers crossed that the EMDR will help your son. I've heard good things about it.

PDU, I was on trazodone for a month or so in the autumn, at 50mg. I stopped it and went back to mirtazapine, but neither helped me sleep so I stopped mirt too. I increased to 150mg last night but it does nothing for me. I get really agitated when I can't sleep so tried to get up. Almost passed out, checked my BP which was 78/38! Quetiapine plunges my BP and I'm sure that can't be safe! They've told me not to decrease it, but I might do anyway :wacko:

pulisa
19-01-20, 19:51
I think psychiatrists are a law unto themselves, DS. They certainly don't like being challenged however I think it's really important that you stand up for yourself because only you know how you are feeling and how these meds affect you personally. I wouldn't be happy with the regime you are on-how on earth are you meant to function even relatively normally?

Have you met this CPN before?

Dying_Swan
20-01-20, 08:42
Thanks Pulisa. I have met the CPN before, but I think I will need to be clearer about things. Took over 3 hours to get to sleep last night, despite all these tablets that are supposed to help. I think the quetiapine dose is too high, and the trazodone does absolutely nothing. I'm also going to see my GP who will hopefully listen a bit more than the psych. You'd think a psychiatrist would be good at listening?! I hope you have a good day.

pulisa
20-01-20, 09:00
Psychiatry tends to attract "interesting" people!! I'd certainly talk about your concerns with the CPN-it sounds as though this meds regime needs adjusting. Do you get motor akasthisia as well as mental? I think you need to get some control back as to which drugs you take because if they don't improve the quality of your life after a reasonable amount of time then questions need to be asked to the prescriber.

Good luck today, DS!

panic_down_under
20-01-20, 10:20
PDU, I was on trazodone for a month or so in the autumn, at 50mg. I stopped it and went back to mirtazapine, but neither helped me sleep so I stopped mirt too. I increased to 150mg last night but it does nothing for me.

So trazodone has been prescribed only as a sleep aid, not as an antidepressant? If so, the higher the dose the lower the sedation. You may have also found 12.5-25mg more effective than the 50mg.


I get really agitated when I can't sleep so tried to get up. Almost passed out, checked my BP which was 78/38! Quetiapine plunges my BP and I'm sure that can't be safe! They've told me not to decrease it, but I might do anyway :wacko:

The trazodone probably paid a part in that too. Have you told them how low your BP is getting? If you have and they aren't taking action then backsides need kicking...swiftly. 78/38 is definitely of concern, not only for the cardiovascular system, but also because of the risk of injury from passing out, etc.

panic_down_under
20-01-20, 10:22
Psychiatry tends to attract "interesting" people!!

Many of them are stark raving bonkers, ime. Crazier than most of their patients. :wacko:

pulisa
20-01-20, 14:05
Many of them are stark raving bonkers, ime. Crazier than most of their patients. :wacko:

I know!! I once saw one who was obviously undiagnosed ASD (no one would have dared suggest it) and his social skills were virtually zero. He was my consultant in hospital though so I had to be careful about what I said..I didn't want to get sent "upstairs"!!

Dying_Swan
20-01-20, 17:55
So true. Im finding negotiating NHS mental healthcare quite challenging. I spent months begging for help, and now I'm supposedly "being helped" it's a bit of a nightmare! But, I'm scared of not being helped too, if that makes sense.

I do get motor akathisia, and wouldn't wish it on anyone. I didn't realise you could have mental akathisia too. What is that like? Maybe that explains the agitation. I've tried to describe it as feeling like my spine has been wired up to the national grid, and you HAVE to move, but with that BP it's hard to move. I told the CPN who said she'll talk to the psych, and also ask about another opinion. I'm worried that might affect the therapy they've offered me, but I can't be doing with a shrink who changes his mind and doesn't admit it. On the upside, my GP did listen and is going to write to the psych to say this med regime isn't working. He's also given me some zopiclone. Haven't had that for donkeys years but worth a try.

Im not sure if they gave me trazodone just for sleep, or also as an antidepressant. I mentioned to my GP I thought it would be more effective at a lower dose. I didn't realise that could also affect my bp. I also take propranolol at night for the akathisia, but no doubt that doesn't help BP or sleep. Feels like I'm on a totally conflicting meds combo!

Thanks guys. I really appreciate your support.

pulisa
20-01-20, 20:48
So you are taking meds to control the side effects of other meds....I'm sure you could be prescribed a different meds regime which actually treated your diagnosed condition but that's the beauty of the NHS' mental health services..If you don't tick the right boxes you are left in that murky grey area. Don't let that happen to you, DS. Get that second opinion to which you have a right. Don't let them fob you off with meds which don't suit you or your illness.

panic_down_under
20-01-20, 22:55
I told the CPN who said she'll talk to the psych, and also ask about another opinion.

I agree with pulisa, get a second opinion. All three of your meds, quetiapine, trazodone and propranolol lower BP.


Im not sure if they gave me trazodone just for sleep, or also as an antidepressant

You need to get an answer on this. 150mg is too high for sedation, but borderline as an antidepressant with most needing at least 225mg to begin seeing positive results and many on 300mg plus.


I also take propranolol at night for the akathisia

Propranolol is probably the most effective med for akathisia at doses of around 40-80mg, but obviously not ideal with your current med mix. The benzodiazepines are pretty good too, which I'm guessing why your GP prescribed zopiclone, but I can't say whether the 'Z' hypnotics are as effective as the BZDs.

Really the best option would be to at least lower the quetiapine dose, but I can understand why they're reluctant to do so while the trazodone dose is being ramped up. Changing two meds at the same time is fraught as working out which med is causing an issue become more difficult.

pulisa
21-01-20, 08:44
I found diazepam worked best for mental akasthisia-80mg propanolol didn't do anything. Zopiclone wasn't terribly helpful either. It's a tricky situation because many of these meds just make agitation worse-one reason I don't take them!

Dying_Swan
21-01-20, 09:35
Thanks both. I will see about that second opinion. I don't want to rock the boat but something has to change. I'm taking both propranolol and omeprazole to counteract side effects. I'm also in the process of getting off venlafaxine. Now down to 9mg daily! I'm tapering off more slowly than I was meant to as I'm really sensitive to ven withdrawal. I have said I want to reduce quetiapine but they said not at the same time as changes trazodone and ven, like you said PDU.

i will ask whether the trazodone is for sleep or AD, though the letter I got suggests its for sleep. I took zopiclone last night and slept through the akathisia. A relief. I've only got 14 so thought I'd try to use them only when I can't sleep. I do also have some lorazepam and diazepam, which can be helpful for agitation but not enough for sleep. I've suggested a general anaesthetic, but that's not an option :D I often think of you and that stun gun Pulisa! How does mental akathisia affect you?

pulisa
21-01-20, 14:01
I'm unable to sit down or sit still, can't concentrate on anything, need to keep moving at all times, unable to sleep etc. Also a terrible sense of inner turmoil and restlessness-it just feels unbearable. I have never been able to understand how people can't get out of bed with anxiety-for me it's the opposite. I love the after effects of a general anaesthetic and that sense of relaxation:D

Dying_Swan
21-01-20, 19:20
Oh wow, yes that's exactly it. It doesn't feel quite like anxiety to me, although similar, but there's a bit of a rage about it too. Immense frustration. I have told them that a punch bag would be more helpful to me than the usual warm bath/jigsaw puzzle/read-a-nice-book suggestions they inevitably come up with. Id love a trampoline I could use at 4am, although not sure how that'd work with low BP :D After some advice from mind today, not sure if I'm going to get another opinion, as if they change things again I might not get any further help. At the least I'm going to ask for the psych to see me again and explain his decisions. I'm sure that changing my mind won't go down well, but if the shrink can change his mind, I reckon I can too. Wishing you a peaceful and akathisia-free evening :)

pulisa
21-01-20, 19:58
Thanks, DS. You too! I agree about the anger/rage factor. I still stand by my agitated depression diagnosis of 25 years standing plus a few "extras"!:D

Dying_Swan
22-01-20, 13:29
I'm sorry you get it too. It's so hard to explain to someone who hasn't had it. Ive just had the CPN on the phone- they're sorting another opinion and tell me it won't impact on therapy they're offering (hmmm), and I should reduce quetiapine by 50mg at a time (not possible with the tablets Ive got) to whatever dose I want:shrug: And they want a list of blood pressures, so I'll have to avoid zopiclone for a bit to "prove" I'm not making it up and it really does drop.

pulisa
23-01-20, 08:34
Well that's certainly helpful advice re the quetiapine and it doesn't surprise me. I'm sure you will find some improvement by reducing the dose and you may feel better on less medication in general. Let us hope that the "alternative opinion" is a bit more clued up.

Dying_Swan
23-01-20, 12:40
Well that's certainly helpful advice re the quetiapine and it doesn't surprise me

:roflmao:Thank you, that did make me chuckle. I didn't take zopiclone last night and was up half the night in order to record my low BP. I need to do it again too to get it while I'm standing up, if I can stand up. I'm sure there are some ethical considerations somewhere here.

I hope you and your son are doing ok. Thank you so much for your support

pulisa
23-01-20, 14:07
Do they really mean that you should take your BP during the night? Surely it should be during the day only? I would have thought that the aim would be to get you back to a normal sleep/awake cycle with the prescribed meds combo working in your favour as opposed to against it?

Has any drug been better for you than others? I think you should have a say in what you would like to try next because you know how you react and having confidence in a med can be half the battle whether it's a placebo effect or not.

Dying_Swan
23-01-20, 16:30
Maybe you're right and they only want daytime BPs, but it's in the few hours immediately after taking quetiapine that it plummets, and I feel like I need to prove it. If they could see my other medical records they'd have proof, but annoyingly they're on different systems. I'm not going to do this for any longer than I have to though.

Truthfully, none of the meds have done much for me, with the exception of benzos. Mirtazapine was initially fantastic for sleep but only for a couple of months. I've had a couple of weeks with different med combos where I felt better, but nothing has made a sustained difference, and they are saying now that meds are likely to only have "limited benefit". The private psych I was seeing previously felt I was calmer on quetiapine. I don't mind continuing it, as long as I can get the side effects sorted, so probably a lower dose. I do want to come off trazodone though, as it's never done anything for me. They've arranged a review with the shrink next week, so will see what he says. Thank you for your sound advice.

pulisa
23-01-20, 18:04
"Limited benefit" is the classic fob off because it means nothing. I would have thought that getting your sleep sorted into a reasonable and consistent pattern should be of paramount importance? If the lower dose of quetiapine suits you and acts as an add-on to boost anti depressant efficacy then this would be ideal but I know it's not as simple as that. I know my son has risperidone to limit rumination/self harm/ suicidal ideation in conjunction with 225mg ven but he is on a low dose(2mg) to limit akasthisia. Doesn't help with sleep though although he takes it at night but he has ASD so things are more complicated and his ruminations are solid and unreachable.

Glad you've got a review next week. Don't be afraid to speak your mind because you will still get that promised therapy. You are just being assertive and not just "taking" whatever is dished out by a wishy washy psych!

Dying_Swan
23-01-20, 23:21
Thank you, and you're right about getting my sleep sorted. I'll try to get a BP reading tonight after quetiapine, and hopefully that'll be enough. I've written down some questions for the psych appointment next week too, as I find the appointments quite stressful and end up zoning out.

How is your son doing? Has he started the EMDR yet? I'm sorry he is still struggling with sleep. It's such a basic thing but has such a huge impact.

pulisa
24-01-20, 08:56
Good idea to get your questions written down-I think psychiatrists often have their own agenda for these reviews and you end up not being able to say what you really want to say.

My son isn't good but he starts his EMDR therapy on Tuesday. I will admit that I'm worried that he won't be able to cope with the repercussions but I'm probably being over cautious. It's a whole new treatment programme so for me it's just fear of the unknown and I'm the one who will have to deal with the fall out...if there is one!

Dying_Swan
24-01-20, 13:51
They definitely do seem to have their own agenda! I got some bp readings but typically it didn't go as low as it sometimes does, except for standing BP when I woke up, which was unreadable.

From what little I've read about EMDR, it's very effective, although the reason for that isn't clear. I would think it will be very important for the therapist to give your son some grounding techniques while he's going through this, and also some crisis planning if that's a possibility. Hopefully they will also have some clue as to how his ASD affects him. Please do let me know how he gets on. I hope you have some support too.

pulisa
24-01-20, 17:55
No support for me and, more importantly, none for my daughter either who is suffering horribly and on 24/7 alert but we are just collateral in all this.

The therapist is a psychologist who specialises in ASD so is ideal. Not available locally of course but hopefully worth the journey.

Thank you for your good wishes, DS. I really do hope you get a decent second opinion and that you have some rapport and respect for the new psych..Can make all the difference, can't it? Just knowing you are on the same wavelength...

Dying_Swan
24-01-20, 22:47
Thank you. They're sending me miles away for the second opinion, just like your son's psychologist, but hopefully it'll be worth it on both counts. I'm sorry it's so hard on you and your daughter. You'd think they'd see the value in caring for carers. Keeping my fingers crossed for you, and your son and daughter. I will be thinking of you and hoping this treatment will make a positive difference for you all.

pulisa
25-01-20, 08:23
Thank you, DS! I'm sure the therapy will help and if it doesn't at least we will have tried to make things more tolerable for him. I could probably make more fuss about the carer support aspect but I just can't be bothered with having people round to discuss my "needs". i'm more concerned about my daughter's very fragile and fearful state.

Fingers crossed for your second opinion and I hope that a change of psych and location could be the start of better and more appropriate care for you. My daughter had to go out of county for some ACT therapy a few years back and it was very successful. You realise that there are some much better services elsewhere but you have to persevere to get access to them!

Dying_Swan
25-01-20, 13:42
Thank you Pulisa. You've been a huge support. It'll be my third opinion, as the first two are conflicting. The private psych had a different opinion to the NHS one, although I know they had a discussion. I think I will ask whether the private one eventually agreed, as if there is agreement between two, I'll find things easier to accept.

I hope that your daughter is getting some support, beyond you having to cope with everything. Ive said it before and I'll say it again, I take my hat off to you. Having a psychologist who specialises in ASD will hopefully be really helpful. I think your son and daughter are very lucky to have you as their mum.

pulisa
26-01-20, 08:47
Thank you but I'm certainly not a great example for them!

You could see 5 different psychiatrists and get 5 different diagnoses and meds regimes, I reckon! So much depends on getting an accurate diagnosis and so much hinges on the expertise and area of interest of the psychiatrist. I'm not sure how helpful "labels" are-I'm more interested in getting the right treatment for the symptoms as diagnoses can vary from expert to expert.

Dying_Swan
26-01-20, 16:58
I think you're spot on. It all just seems to be a matter of opinion, or a guessing game. Slap a label on, swallow these pills and ask no questions. Still, the psychologist said the same as you, about treating symptoms and not labels, so vaguely optimistic about that. Hope your week goes well.

Dying_Swan
29-01-20, 15:47
Updating this as a sort of diary I guess. Today I have seen the psychiatrist, CPN and psychologist. Full on. As it seems there was no consensus between the private and NHS psychs on diagnosis, I'll go for the second opinion and am assured it won't affect the therapy I'm waiting for.I took a strip of 100mg quetiapine with me, to prove you can't halve them. I hate feeling that I have to prove everything, but I do. Anyway, meds-wise I said I didn't want to change everything at once (came off venlafaxine 4 days ago and still getting head shocks). So I've got to taper down and stop trazodone, start pregabalin, and stay at 600mg quetiapine for now. Shrink says pregabalin will help with sleep, but I'm not convinced so might ask GP for more zopiclone. Other future possibilities are clomipramine or promethazine, although I'm reluctant to try further antihistamines.

pulisa
29-01-20, 18:12
I'm so sorry that there was no consensus re diagnosis but this is typical of psychiatrists. Doesn't help you one iota of course. Your best bet may be the promised therapy-meds are such a lottery and it's often down to each psychiatrist's personal preference regardless of your particular circumstances.

My son has tried most of the sleep "aids"-have you ever tried melatonin on prescription? One psychiatrist prescribed amitryptiline 25mg as a knock out drug whilst another said they had never used it as a sleep inducer...It's all so confusing and unsettling when you just want an informed and definitive opinion. But nothing is straightforward with mental health, is it?

Dying_Swan
29-01-20, 19:29
You're quite right, it really isn't! Thanks P. I haven't tried melatonin but had considered buying it online. Was it any good? I had a small dose of amitriptyline years ago, and my mum swears by it, but they won't prescribe it for me and said clomipramine would be better if the pregabalin doesn't work out. I definitely agree that therapy is more likely to help than meds.

I was hoping the shrinks would agree, but apparently not, so will do the long drive to see what the third one says. I'm wondering if the NHS teams will "stick together" though. The psychologist says she doesn't use labels at all, whilst I've lost track of what labels I do and don't have. The case continues :wacko::roflmao:

pulisa
29-01-20, 19:53
I suspect the NHS teams will stick together. One NHS psych told me that when you pay to see a private psych you have more time so they have to diagnose you with more stuff so that you feel you are getting your money's worth....She was pretty clueless though and we have progressed to "higher" levels of competence!

Dying_Swan
30-01-20, 15:54
That's interesting, and the opposite to my experience. The private psych gave me fewer labels than the NHS, although it took a long time to get the NHS to take me seriously. I had more faith in the private one, simply because he was older and I think more experienced, and seemed more quietly confident to me, but it became prohibitively expensive and I could see how it wasn't going to work having both involved. I'm almost hoping the next one I see will just stick with things as they are as don't know if I can cope with everything being changed again. We shall see. Thanks P, as ever you have been a huge support x

pulisa
01-02-20, 14:14
I hope you get some sort of agreement in treatment procedure, DS. Really unsettling when you have to suffer as a result of meds changes which could have been avoided with a clear and definitive diagnosis in the first place but we are dealing with psychiatrists here and anything goes because they are covered for every eventuality due to the unpredictability of mental health.

Dying_Swan
01-02-20, 18:15
we are dealing with psychiatrists here and anything goes because they are covered for every eventuality due to the unpredictability of mental health.

Such a scary thought. So much of it seems to be guesswork but the impact of getting it wrong is so potentially damaging. Thank you for your good wishes x