Struggling again

[Jo79]

Well here we go again...I have had a rough couple of months with more bad days than good so psychiatrist has increased my venlafaxine to the maximum 375mg (also still on 300mg quetiapine and 45 mirtazapine so on the maximum dose of everything now 😬).

I’m getting the obsessive intrusive thoughts again and generally feeling very unhappy. I have to admit after 18 months on venlafaxine I have really only had 2 or 3 months of feeling reasonably ok, but I don’t think I have ever felt like my old self. She’s there somewhere deep down and I get the occasional glimpse but not for long.

Will just see how this increase goes, getting the usual increased anxiety and racing brain. It’s been 10 days now so hopefully I will see a difference soon. Psychiatrist has suggested I could try fluoxetine next but it would mean tapering off ven first which will be great fun from 375mg! 🤦*♀️

[panic_down_under]

Well here we go again...I have had a rough couple of months with more bad days than good so psychiatrist has increased my venlafaxine to the maximum 375mg (also still on 300mg quetiapine and 45 mirtazapine so on the maximum dose of everything now 😬).

I’m getting the obsessive intrusive thoughts again and generally feeling very unhappy. I have to admit after 18 months on venlafaxine I have really only had 2 or 3 months of feeling reasonably ok, but I don’t think I have ever felt like my old self. She’s there somewhere deep down and I get the occasional glimpse but not for long.

That's a lot of medication for what seem to be only moderate results, Jo. I'm wondering whether it is doing more to bury 'her' than lift her up, especially the quetiapine and mirtzapin.


Will just see how this increase goes, getting the usual increased anxiety and racing brain. It’s been 10 days now so hopefully I will see a difference soon. Psychiatrist has suggested I could try fluoxetine next

Are the intrusive thoughts the main problem? Also, what other ADs have you tried in the past with what result?


but it would mean tapering off ven first which will be great fun from 375mg!

Because weaning off venlafaxine can be difficult due to its short half-life the preferred method of stopping is to switch to the longer acting fluoxetine instead and then weaning off it. The standard recommendation (PDF (https://www.sps.nhs.uk/articles/how-do-you-switch-between-tricyclic-ssri-and-related-antidepressants/), chart pge 7) is a direct switch, but I'd go with a cross-taper. Either way, some caution is needed, but a competent psychiatrist should be able to guide you through this, Jo.

[Jo79]

Thanks PDU, yes it’s the thoughts that are the main issue. The psychologist I was seeing last year seemed pretty sure it is relationship OCD.

Over the years I have tried Citalopram which worked well twice but not so good a third time, Sertraline which worked well for a couple of years at various doses but then GP added mirtazapine as it seemed to lose its effect. Escitalopram worked great but I had a massive blip after a night of heavy drinking (and my GP reduced my thyroxine after 30 years on the same dose which turned out to be a bad idea) my psychiatrist then decided to change to venlafaxine and then added quetiapine after a few months with little improvement. I kind of wish I had stuck with the escitalopram now.

Funnily enough I started to see some improvement after I demanded that my levothyroxine dose be put back up. For months I was tired all the time which was just adding to the depression and was convinced it was due to the lower dose but my GP kept brushing it off 🙄.

I still feel like my energy levels and depression are much improved but now it’s just the constant intrusive thoughts bombarding me and getting me down.

[panic_down_under]

Thanks PDU, yes it’s the thoughts that are the main issue. The psychologist I was seeing last year seemed pretty sure it is relationship OCD.

...Over the years I have tried Citalopram which worked well twice but not so good a third time, Sertraline which worked well for a couple of years at various doses but then GP added mirtazapine as it seemed to lose its effect. Escitalopram worked great but I had a massive blip after a night of heavy drinking (and my GP reduced my thyroxine after 30 years on the same dose which turned out to be a bad idea)

Unfortunately, alcohol and anxiety disorders, or depression are not a good mix, Jo. While it is by far the most (self)prescribed 'med' for these disorders it actually makes then worse because it causes the very brain deficit that manifests them by inhibiting the growth (http://www.ncbi.nlm.nih.gov/pmc/articles/PMC60045/) of new brain cells in the hippocampal regions (neurogenesis). Both ADs (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3025168/) (and therapy (https://doi.org/10.1016/j.biopsych.2013.05.017)) work by stimulating the growth of new hippocampal cells. The new cells produce the therapeutic response, not the meds/therapy directly. Even moderate drinking can result in significant hippocampal atrophy (https://www.popsci.com/moderate-drinking-bad/) (Topiwala A (https://www.bmj.com/content/357/bmj.j2353), 2017; - see also: Anderson ML (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4568748/), 2012; 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).


My psychiatrist then decided to change to venlafaxine and then added quetiapine after a few months with little improvement. I kind of wish I had stuck with the escitalopram now.

I'm not a fan of poly-prescribing. It may sometimes be necessary, but should be very much a last option, not the first. Just throwing more and more meds at a problem in the vain hope that something will stick rarely works, and even when it does the response is usually because of the last drug taken, not the combo, so what is the point of continuing to take the failures?

My suggestion is you give the escitalopram another try and if it works then wean off the quetiapine and mirtazapine. If it doesn't then ask for clomipramine (Anafranil), one of the older TCA antidepressants which has a very good track record for OCD spectrum disorders. I would have suggested it as the first option but switching to it from venlafaxine can be tricky so transitioning to a SSRI first is probably the better option and it then might as well be escitalopram.

Irrespective of which way this goes, when you are finally on a med that works well for you seriously consider staying on it permanently, Jo. There is now considerable evidence ADs become progressively less effective every time they are stopped and restarted, often requiring higher doses to achieve the previous level of control, or not working at all. They may also produce more severe, and/or different, initial side-effects. Two studies, Amsterdam JD (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5123793/), 2016 and Amsterdam JD (http://www.karger.com/Article/FullText/226611), 2009, found the likelihood of antidepressants working after each restart drops by between 19-25% (see also: Bosman RC (https://www.ncbi.nlm.nih.gov/pmc/articles/pmid/30041180/), 2018; Amsterdam JD (http://www.ncbi.nlm.nih.gov/pubmed/18694599), 2009; Leykin Y (http://www.ncbi.nlm.nih.gov/pubmed/17469884), 2007; Paholpak S (https://www.ncbi.nlm.nih.gov/pubmed/12501907), 2002).

[Jo79]

Three weeks into 375mg. Feel no different except maybe a bit more depressed - I’m in hospital Wednesday to have a gastroscopy due to constant acid reflux and I actually hope they find something seriously wrong as i’m just so done with life now.

[panic_down_under]

Three weeks into 375mg. Feel no different except maybe a bit more depressed - I’m in hospital Wednesday to have a gastroscopy due to constant acid reflux and I actually hope they find something seriously wrong as i’m just so done with life now.

Please see your psychiatrist or GP asap, Jo, and tell him/her/them about your current state of mind. It's time for your med regime to be reassessed, imho.

[Jo79]

I think you’re right, PDU. Only thing is I’m absolutely terrified at the prospect of tapering from 375mg. My psychiatrist said a cross taper isn’t advisable as I’m also on a high dose of mirtazapine and quetiapine so I have to taper down to 75mg before introducing something else (probably fluoxetine). I have read somewhere that taking diphenhydramine can help withdrawals and I also have some diazepam if that would help. I’m due to have my next appointment with the psychiatrist on Friday.

[panic_down_under]

My psychiatrist said a cross taper isn’t advisable as I’m also on a high dose of mirtazapine and quetiapine so I have to taper down to 75mg before introducing something else (probably fluoxetine).

Given that neither mirtazapine and quetiapine seems to be going much either is reducing their doses, or quitting them first an option? Might be easier than tapering down to 75mg of venlafaxine.


I have read somewhere that taking diphenhydramine can help withdrawals.

Diphenhydramine is an antihistamine and in some countries the main ingredient in Benadryl (but not in the UK where it is formulated with less sedating alternatives). As mirtazapine is a potent antihistamine I don't know that diphenhydramine will help much. Quetiapine also has antihistamine activity.

[pulisa]

I think you’re right, PDU. Only thing is I’m absolutely terrified at the prospect of tapering from 375mg. My psychiatrist said a cross taper isn’t advisable as I’m also on a high dose of mirtazapine and quetiapine so I have to taper down to 75mg before introducing something else (probably fluoxetine). I have read somewhere that taking diphenhydramine can help withdrawals and I also have some diazepam if that would help. I’m due to have my next appointment with the psychiatrist on Friday.

My son was able to taper down from 375mg venlafaxine and cross over onto 20 mg vortioxetine in a matter of a few weeks. He had no side effect at all. He is also on 400mg quetiapine.

I feel for you, Jo but you definitely shouldn't be taking a high dose of a med which is doing nothing for you. Good luck for tomorrow..You don't really mean what you say, I'm sure but I totally get your desperation.

[Jo79]

My son was able to taper down from 375mg venlafaxine and cross over onto 20 mg vortioxetine in a matter of a few weeks. He had no side effect at all. He is also on 400mg quetiapine.

I feel for you, Jo but you definitely shouldn't be taking a high dose of a med which is doing nothing for you. Good luck for tomorrow..You don't really mean what you say, I'm sure but I totally get your desperation.

Thanks Pulisa, so glad your son managed the change ok, how is he doing on the vortioxetine now?

my psychiatrist suggested vortioxetine initially but then decided fluoxetine might be a better bet because of the OCD and also because I am struggling to control my binge eating :blush: I’m in a vicious circle, mirtazapine and quetiapine are making me pile on the weight which is probably the cause of the acid reflux but I’m reluctant to come off either of these as they really help with sleep. I’ve never really been very impressed with venlafaxine and there has always been that underlying worry around withdrawal. I think I just need to crack on with it and try not to jump to conclusions, it might not be that bad after all.....:madness:

[pulisa]

My son had no knowledge about potential withdrawal symptoms or as they say.."discontinuation" symptoms..He just went along with the regime. I don't think the vortioxetine has done anything at all to be honest.

The quetiapine has restored his sleep and has limited the self-harming..It does cause the munchies though as you know! Mirtazapine is just an appetite-stimulant..It's even used with cats to make them eat after surgery!

I think you should crack on with coming off ven and look at it as a big step in the right direction?Give fluoxetine another go if that has been suggested? You need a fresh approach. Good luck tomorrow!

[Jo79]

So the gastroscopy went well and they didn’t find anything serious, just a case of GORD which I have been given omeprazole to take and this seems to help.

WRT ven withdrawal I have just reduced to 225mg after a few days on 300mg. The psychiatrist wants me to reduce by 75mg every few days and then start Fluoxetine. I am having rather a strange experience though...instead of feeling bad effects from withdrawal I am actually feeling BETTER each time I reduce the dose (??!!??)

Hope it continues but I’m preparing myself in case it doesn’t 😂

[pulisa]

You're probably feeling better because you have a plan to change meds rather than continuing to flog a dead horse?

Good news about the gastroscopy..although GORD is a pain.

Don't anticipate "trouble"..It may never happen. Take it a day at a time and look forward to a new regime and a fresh start? You'd more than given ven a chance at the highest dose (without hospitalisation).

[panic_down_under]

WRT ven withdrawal I have just reduced to 225mg after a few days on 300mg. The psychiatrist wants me to reduce by 75mg every few days and then start Fluoxetine. I am having rather a strange experience though...instead of feeling bad effects from withdrawal I am actually feeling BETTER each time I reduce the dose (??!!??)

Given you increased to 375mg not that long ago the higher dose might have been producing more negative than positive effects and the drop back to 225mg has bought you back to a more tolerable space. This is one of those situations where it doesn't pay to look at the gift horse's dental work, but give thanks to the fates for small mercies. Fingers crossed that it continues, Jo. 🤞

[Jo79]

Well I’m finally off the venlafaxine and I’m relieved to say that other than tiredness, body aches and a little bit of dizziness it really hasn’t been that bad! OCD symptoms have actually improved a bit and the low mood certainly hasn’t worsened 🙂

Day two of 10mg fluoxetine now and moving up to 20mg on Tuesday. Thank you to everyone that has offered advice on here, I have really appreciated it. Maybe speak to you soon on the fluoxetine section but fingers crossed 🤞 it will all go smoothly 😁

[pulisa]

The very best of luck with the prozac, Jo. It's got to be better than mega venlafaxine and it's a whole new regime for you and a fresh start.

[panic_down_under]

Well I’m finally off the venlafaxine and I’m relieved to say that other than tiredness, body aches and a little bit of dizziness it really hasn’t been that bad! OCD symptoms have actually improved a bit and the low mood certainly hasn’t worsened 🙂

That's great Jo. :) Our fears of change are often far worse that the actuality.