Citalopram 10mg > 20mg

[EnoughAlready]

Hi,

been on 10mg of Cit since May 2020 for anxiety, recently asked doc to up it to 20mg, 4 days in and I feel light headed, pretty out of it and abit sick. Similar to symptoms when I first took 10mgs

Is this normal? How long does it take for your body to adjust to new dose and feel the benefit?

Thanks

[panic_down_under]

been on 10mg of Cit since May 2020 for anxiety,

10mg is a sub therapeutic dose for most which may increase the risk of the med pooping-out.


recently asked doc to up it to 20mg, 4 days in and I feel light headed, pretty out of it and abit sick. Similar to symptoms when I first took 10mgs

Is this normal?

Yes, it is normal. Serotonin isn't only a brain neurotransmitter. In fact that is one of its lesser functions. When the dose is increased there is usually an immediate increase in serotonin activity which may effect not only the brain, but all the other serotonergic organs for a while just as it did when you first began taking citalopram.


How long does it take for your body to adjust to new dose and feel the benefit?

The heightened serotonin activity will usually trigger bio-feedback mechanisms to reduce serotonin synthesis and expression back to baseline, or below, within a couple of weeks after which the side-effects should begin to diminish.

It may take longer for anxiety levels to ease. Antidepressants don't direct treat anxiety (or depression) in the way benzodiazepines do, but work by stimulating the growth of new brain cell (neurogenesis) in the hippocampal regions of the brain to replace cells killed or prevented (http://www.ncbi.nlm.nih.gov/pmc/articles/PMC60045/) from growing by high brain stress hormone levels and these new cells take time to grow and mature. Incidentally, the cognitive, behavioural (CBT, REBT, etc) and mindfulness therapies also work (https://doi.org/10.1016/j.biopsych.2013.05.017) by hippocampal neurogenesis as does exercise (https://doi.org/10.3727%2F096368910X532846) to a lesser extent although it may be all that's needed for mild anxiety and/or depression.

[EnoughAlready]

thanks for the response :) Good info.

[LilyPad1991]

10mg is a sub therapeutic dose for most which may increase the risk of the med pooping-out.


This is interesting Panic Down Under, do we know why this is?

I’m especially interested as I had been very slowly tapering off 60mg duloxetine since August 2022 (reducing my 5% of previous dose every 2 weeks). I have been very well on duloxetine for 10 years but wanted to come off the drug to consider having children. When tapering, upon getting to 25% of the original 60mg dose I realised I was heading towards a significant anxiety relapse. With the support of my doctor I have gone up to 30mg then 40mg then 50mg of duloxetine and now am on day 7 of 60mg. I think things are improving but I’m so worried I’ve broken my brain and impatient to feel well again. Can you share any thoughts or insights?

Thank you.

[panic_down_under]

do we know why this is?

Antidepressants - also the cognitive, behavioural (CBT, REBT, etc) and mindfulness therapies (https://doi.org/10.1016/j.biopsych.2013.05.017) - work by stimulating the growth of new brain cells (neurogenesis) to replace cells killed, or prevented from growing by high brain stress hormone levels (PDF (https://www.americanscientist.org/sites/americanscientist.org/files/20057610584_306.pdf)). The therapeutic response is produced by these new cells and the interconnections they forge, not the meds directly.

Most serotonergic ADs need to be taken at doses high enough to saturate 80% (https://pubmed.ncbi.nlm.nih.gov/15121647/) of the serotonin transporters (5-HTT) to initiate and sustain neurogenesis. Unfortunately, there is no readily available test to determine the dose needed to achieve this for individuals so the minimum recommended dose is calculated to ensure at least 80% saturation for everyone.

The problem with taking sub/borderline therapeutic doses is neurogenesis may be interrupted whenever AD plasma levels drop below the amount needed to sustain it which could lead to the second issue, the growing evidence antidepressants become progressively less effective every time they are stopped and restarted. Two studies, Amsterdam JD (https://www.ncbi.nlm.nih.gov/pubmed/27805299), 2016 and Amsterdam JD, 2009 (http://www.karger.com/Article/FullText/226611) found the likelihood of 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). Taking a low dose for months may create a similar situation as stopping and restarting it. While the neurogenesis interruptions may only be of short duration, they will probably occur much more frequently.


I'm especially interested as I had been very slowly tapering off 60mg duloxetine since August 2022 (reducing my 5% of previous dose every 2 weeks).

How were you able to reduce the dose in 5% steps given the med comes in only a limited number of dose sizes and the pills cannot be cut?


I have been very well on duloxetine for 10 years but wanted to come off the drug to consider having children.

You probably don't need to come off ADs before becoming pregnant. With the exception of paroxetine (Paxil) it is unclear that antidepressants significantly increase the odds of birth defects or complications. Studies have reported higher incidents of defects, but there doesn't seem to be a common pattern to them which may indicate the studies aren't showing a real issue, but just reporting statistical noise. The problem is that the number of patients in each study tends to be low, the defects tend to be mostly the rare ones and the increases they report are often small. To complicate matters, there is evidence that maternal anxiety (and/or depression) can adversely affect the fetus, both immediately, and later in life.

If planning to breastfeeding then sertraline (Zoloft) may be the best bet as very little, if any sertraline is expressed in the milk (Pinheiro E (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4366287/), 2015).

Unfortunately, antidepressants and pregnancy is an issue where there is no clear cut 'right' answer. I suggest you discuss this thoroughly with your family doctor and obstetrician and/or gynecologist well before becoming pregnant and follow their recommendations.


I'm so worried I've broken my brain and impatient to feel well again.

You haven't "broken" your brain. Until a couple of decades ago it was thought that the brain we got at birth was the brain we had for life, but it turns out that it is in fact a fairly malleable organ which can undo considerable damage if given the chance.

[LilyPad1991]

Antidepressants - also the cognitive, behavioural (CBT, REBT, etc) and mindfulness therapies (https://doi.org/10.1016/j.biopsych.2013.05.017) - work by stimulating the growth of new brain cells (neurogenesis) to replace cells killed, or prevented from growing by high brain stress hormone levels (PDF (https://www.americanscientist.org/sites/americanscientist.org/files/20057610584_306.pdf)). The therapeutic response is produced by these new cells and the interconnections they forge, not the meds directlyÂ…Â….

Thank you, this is really helpful. I’m on day 9 of being back on 60mg and it definitely caused an increase in anxiety and depression symptoms, psychological and physical. I think these are slowly reducing now but it did scare me. Duloxetine worked so well for me for so long and I’m worried I’ve ruined that by trying to come off it.



How were you able to reduce the dose in 5% steps given the med comes in only a limited number of dose sizes and the pills cannot be cut?

The duloxetine capsules contain microbeads: I found the average weight of a 60mg capsule’s microbeads and reduced the dose by 5% of the previous weight every 2 weeks. I then increased the reduction to 7.5% and then 10% every two weeks and I think that increase, combined with an array of work and personal life circumstances and stresses resulted in this significant anxiety relapse. I am aware that tampering with the beads is against the manufacturers advice but given that the dose sizes are so limited and the withdrawal off duloxetine is so intense, it’s a decision I made.




You probably don't need to come off ADs before becoming pregnant. With the exception of paroxetine (Paxil) it is unclear that antidepressants significantly increase the odds of birth defects or complicationsÂ…Â…. To complicate matters, there is evidence that maternal anxiety (and/or depression) can adversely affect the fetus, both immediately, and later in life.

This is really interesting too, thanks for sharing. I really wish I’d never tried to come off duloxetine but it’s done now. I thankfully have the support of my GP and have already spoken to an antenatal psychiatric pharmacist too so will take your advice about speaking to as many specialists as I can. The role of maternal anxiety is definitely a big thing to consider given my apparent predisposition to anxiety. The main thing I worry about is the withdrawals experienced by the baby following birth.






You haven't "broken" your brain. Until a couple of decades ago it was thought that the brain we got at birth was the brain we had for life, but it turns out that it is in fact a fairly malleable organ which can undo considerable damage if given the chance.

Thanks for this. I am just worried really, worried that my actions will result in duloxetine no longer working for me.

[panic_down_under]

Duloxetine worked so well for me for so long and I'm worried I've ruined that by trying to come off it.

While discontinuing ADs can increase the risk of them not working, I doubt you have anything to worry about given it was a one off and you didn't actually stop taking duloxetine. Plus, the SNRIs and TCAs tend to be less likely to quit than the SSRIs generally.


I am aware that tampering with the beads is against the manufacturers advice but given that the dose sizes are so limited and the withdrawal off duloxetine is so intense, it's a decision I made.

I agree with the drug company on this, but you'd think by now there would be are greater range of dose sizes available. It has been a problem since duloxetine became available. Until there is I think the TCAs are the better option. They are usually a lot easier to quit. Should you need to come off duloxetine in the future switching to a SSRI and tapering off it may be easier.


The role of maternal anxiety is definitely a big thing to consider given my apparent predisposition to anxiety. The main thing I worry about is the withdrawals experienced by the baby following birth.

I understand your concerns. As per my previous post this is one of those problems which have no right solution. :weep:

[LilyPad1991]

While discontinuing ADs can increase the risk of them not working, I doubt you have anything to worry about given it was a one off and you didn't actually stop taking duloxetine. Plus, the SNRIs and TCAs tend to be less likely to quit than the SSRIs generally.

That’s helpful, thanks for the info and reassurance. Anxiety is so unhelpful when it comes to being rational about these things so I really appreciate you taking the time to respond and speak sense! I know that at 9 days it would be quite unreasonable to expect a dramatic recovery and that patience, mindfulness, breathing etc etc will help me through this rough patch. Impatience is not a virtue!




… I think the TCAs are the better option. They are usually a lot easier to quit. Should you need to come off duloxetine in the future switching to a SSRI and tapering off it may be easier.

Should the need arise, might a TCA be a better option alternative to duloxetine because of the TCA’s action on noradrenaline as well serotonin? Many years ago I was on citalopram but it was never as effective as duloxetine and I moved to duloxetine because of it being an SNRI on the advice of a psychiatrist back in 2012 who felt I would benefit from the serotonin/noradrenaline combo.

Thanks again for your time and knowledge, I really appreciate it.

[panic_down_under]

Should the need arise, might a TCA be a better option alternative to duloxetine because of the TCA's action on noradrenaline as well serotonin?

Imho, yes. The closest TCA to duloxetine in inhibition of both serotonin and noradrenaline transporters is imipramine (Tofranil). This is the first AD I took some 36 years ago (there weren't any SSRIs, or SNRIs then) and it worked fine although I needed to take a very high dose. But that's been true of every other AD I've tried so it almost certainly comes down to my biology/genetics, not the meds.


Many years ago I was on citalopram but it was never as effective as duloxetine

As a generalization the TCAs seem to be a little more effective for anxiety, and have a clear edge for depression.


I moved to duloxetine because of it being an SNRI on the advice of a psychiatrist back in 2012 who felt I would benefit from the serotonin/noradrenaline combo.

It was good advice. The true SNRIs are often very effective, but they have what I consider a major flaw, they all have very short half-lives which means they either need to be taken multiple times a day, or be formulated for slow-release which can make titrating the dose difficult. OTOH, the TCAs have similar half-lives to SSRIs, typically 20-36 h, and because they are also prescribed in small doses for other indications most come in a wide range of dose sizes. For example, most people take 100-150mg of imipramine which is usually available in 10mg, 25mg and 75mg tablets all of which can be cut if needed.

[LilyPad1991]

It was good advice. The true SNRIs are often very effective, but they have what I consider a major flaw, they all have very short half-lives which means they either need to be taken multiple times a day, or be formulated for slow-release which can make titrating the dose difficult. OTOH, the TCAs have similar half-lives to SSRIs, typically 20-36 h, and because they are also prescribed in small doses for other indications most come in a wide range of dose sizes. For example, most people take 100-150mg of imipramine which is usually available in 10mg, 25mg and 75mg tablets all of which can be cut if needed.


Thank you so much for taking the time to get back to me. I’ve been having a really rough time since this relapse, I’ve not been this unwell with anxiety in over 10 years and it’s been horrible.


I’m now on day 10 of being back on 60mg of duloxetine and it’s still a bit of a rollercoaster but I’m hoping I’ll have some relief soon. I’ve seen on other threads that it’s relatively common to experience some symptoms when increasing the dose and I think I’m pretty sensitised at the moment anyway. I just want to feel better. Anyway, thank you again.

[panic_down_under]

I've seen on other threads that it's relatively common to experience some symptoms when increasing the dose and I think I'm pretty sensitised at the moment anyway.

Unfortunately, heightened side-effects and raised anxiety levels often occur when increasing the dose. These usually resolve within a couple of weeks, but it may take longer for the higher dose to produce a positive outcome. Sadly, ADs are not a quick fix. :weep:

[LilyPad1991]

Unfortunately, heightened side-effects and raised anxiety levels often occur when increasing the dose. These usually resolve within a couple of weeks, but it may take longer for the higher dose to produce a positive outcome. Sadly, ADs are not a quick fix. :weep:



Hi again Panic Down Under.

Hope you’re doing ok. I’m having some issues with sleep: basically I can get to sleep for a couple of hours but then from the early hours until it’s time to get up, I’m getting adrenaline rushes that wake me up, one after another. It’s weird because I’m both tired and full of adrenaline. Is this part of the side effects of dose increase do you think? It’s awful.

Any insights welcome. I did wonder if maybe taking propranolol would help during these early weeks of 60mg of duloxetine?

I’m so worried duloxetine isn’t going to work for me anymore… But at the same time, I feel like the fact I’ve had side effects shows my body is ‘acknowledging’ the drug???

[panic_down_under]

I'm having some issues with sleep: basically I can get to sleep for a couple of hours but then from the early hours until it's time to get up, I'm getting adrenaline rushes that wake me up, one after another. It's weird because I'm both tired and full of adrenaline. Is this part of the side effects of dose increase do you think? It's awful.

It could be the dose increase, or it might just be anxiety, albeit maybe exacerbated by the AD.


I did wonder if maybe taking propranolol would help during these early weeks of 60mg of duloxetine?

Propranolol is definitely worth talking to your GP about. Not only should it block most of the adrenaline surge, it should also aid sleep.


I'm so worried duloxetine isn't going to work for me anymore

Bridges, crossing thereof! Try not to ruminating over things you can't control and which probably won't happen anyway. Diversion whenever the mind begins to wander into negativity works. A positive outlook won't improve the odds of a med working, but it can make the wait for it to kick-in more bearable.


But at the same time, I feel like the fact I've had side effects shows my body is 'acknowledging' the drug???

While my impression is that those who have significant side-effects are a little more likely to get a positive result from their AD than those who have no or only mild symptoms, the margin isn't that much, unfortunately. :sad:

[LilyPad1991]

It could be the dose increase, or it might just be anxiety, albeit maybe exacerbated by the AD.



Propranolol is definitely worth talking to your GP about. Not only should it block most of the adrenaline surge, it should also aid sleep.



Bridges, crossing thereof! Try not to ruminating over things you can't control and which probably won't happen anyway. Diversion whenever the mind begins to wander into negativity works. A positive outlook won't improve the odds of a med working, but it can make the wait for it to kick-in more bearable.



While my impression is that those who have significant side-effects are a little more likely to get a positive result from their AD than those who have no or only mild symptoms, the margin isn't that much, unfortunately. :sad:

Thank you so much for your reply and your kind words. I really am struggling. I think I had a rather unrealistic expectation of how quickly I would be ‘better’ again.

What are your thoughts on diazepam? I’ve been given 2mg tablets but I’m scared to use them. My doctor is very responsible and trustworthy but still, I’m scared. Oh the joys of anxiety!!

[panic_down_under]

What are your thoughts on diazepam? I've been given 2mg tablets but I'm scared to use them.

I'm not a benzophobe. I find much of what is claimed about them online is ridiculous and benzophobia has almost become a cult complete with gurus and inane rituals.

Firstly, you already have a dependence on diazepam and its metabolites, plus lorazepam (Ativan) and a number of other benzo like molecules. Benzodiazepine binding sites in the brain require benzodiazepines (BZDs) to activate them. There are no processes within the brain capable of producing them, and while there has been much speculation about how they might be synthesized in the body - gut flora was once thought to be the most likely source - nothing has ever been found despite much research. So it is now generally accepted that we derive all the BZDs we need from food as it has been known since the 1980s that plants make benzodiazepine compounds, and that they are also found in animal flesh and organs [1]. While the quantities we get from food are small, they are not insignificant. BZD can reach pharmaceutical levels and higher in patients with some liver diseases [2]. My guess is BZDs are a plant poison to which animal life, Homo sapiens included, has become so adapted to that we can no longer function without them.

Secondly, while coming off them can be difficult for some there are several ADs which are at least as difficult to quit yet most doctors and psychiatrists prescribe them unconcerned by this. Even quitting aspirin (http://www.gastrojournal.org/article/S0016-5085(98)70307-5/fulltext) can be almost impossible for some. So why the hue and cry over BZDs?

That said, there are a couple of reasons why they should be taken sparely and not as primary anti-anxiety med. Firstly, the uncertainty of being able to get it prescribed in the future, and the possibility of being forced to wean off them quickly if/when your doctors decide they want you off them.

The second is they may significantly reduce the effectiveness of antidepressants by blocking hippocampal neurogenesis which is how ADs create the therapeutic response [3]. In light of these studies benzodiazepines use should probably be limited to a couple of weeks when first taking ADs just to ease the initial increase in anxiety levels, for a while after AD dose increases for the same reason and thereafter for occasional breakthrough anxiety.


References:

[1]
Muceniece R, Saleniece K, Krigere L, et al. (2008)
Potato (Solanum tuberosum) juice exerts an anticonvulsant effect in mice through binding to GABA receptors.
Planta Med. 2008 Apr;74(5):491-6. (Abstract (http://dx.doi.org/10.1055/s-2008-1074495))

Kavvadias D, Abou-Mandour AA, Czygan FC, et al (2000)
Identification of benzodiazepines in Artemisia dracunculus and Solanum tuberosum rationalizing their endogenous formation in plant tissue.
Biochem Biophys Res Commun Mar 5;269(1):290-5 (Abstract (https://pubmed.ncbi.nlm.nih.gov/10694515/))

Sand P, Kavvadias D, Feineis D, et al. (2000)
"Naturally occurring benzodiazepines: current status of research and clinical implications."
Eur Arch Psychiatry Clin Neurosci vol 250(4) p 194-202 (Abstract (http://www.ncbi.nlm.nih.gov/pubmed/11009072))

Kotz U, (1991)
Occurrence of "natural" benzodiazepines.
Life Sci;48(3):209-15 (Abstract (http://www.ncbi.nlm.nih.gov/pubmed/1992279))

Unseld E, Krishna DR, Fischer C, et al (1989)
Detection of desmethyldiazepam and diazepam in brain of different species and plants.
Biochem Pharmacol Aug 1;38(15):2473-8 (Abstract (http://www.ncbi.nlm.nih.gov/pubmed/2502983))

Wildman J, U Ranalder U. (1988)
Presence of lorazepam in the blood plasma of drug free rats
Life Sci 43(15):1257-60 [Abstract (https://pubmed.ncbi.nlm.nih.gov/3172979/)]

Wildmann J. (1988)
Increase of natural benzodiazepines in wheat and potato during germination.
Biochem Biophys Res Commun. Dec 30;157(3):1436-43 (Abstract (https://pubmed.ncbi.nlm.nih.gov/2849941/))

[2]
Baraldi M, Avallone R, Corsi L, et al (2000)
Endogenous benzodiazepines.
Therapie Jan-Feb;55(1):143-6 (Abstract (https://pubmed.ncbi.nlm.nih.gov/10860017/))

Zeneroli ML, Venturini I, Stefanelli S, et al, (1997)
Antibacterial activity of rifaximin reduces the levels of benzodiazepine-like compounds in patients with liver cirrhosis.
Pharmacol Res , Jun;35(6):557-60 (Abstract (http://www.ncbi.nlm.nih.gov/pubmed/9356209))

[3]
Boldrini M, Butt TH, Santiago AN, et al. (2014)
Benzodiazepines and the potential trophic effect of antidepressants on dentate gyrus cells in mood disorders.
Int J Neuropsychopharmacol. Dec;17(12):1923-33 (Abstract (https://www.ncbi.nlm.nih.gov/pubmed/24969726) | Full text (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4374628/))

Sun Y, Evans J, Russell B, et al (2013)
A benzodiazepine impairs the neurogenic and behavioural effects of fluoxetine in a rodent model of chronic stress.
Neuropharmacology. Sep;72:20-8 (Abstract (https://www.ncbi.nlm.nih.gov/pubmed/23639432))

Song J, Zhong C, Bonaguidi MA, et al (2012)
Neuronal circuitry mechanism regulating adult quiescent neural stem-cell fate decision.
Nature. Sep 6;489(7414):150-4 (Article (https://www.kurzweilai.net/how-the-brains-stem-cells-find-out-when-to-make-new-neurons/comment-page-1#comment-96481) | Study full text (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3438284/))

Wu X, Castren E. (2009)
Co-treatment with diazepam prevents the effects of fluoxetine on the proliferation and survival of hippocampal dentate granule cells.
Biol Psychiatry. Jul 1;66(1):5-8 (Abstract (https://www.ncbi.nlm.nih.gov/pubmed/19251245))

See also: the 'Ugly' part of Benzodiazepines: The Good, The Bad, and the Ugly (https://journalofpsychiatryreform.com/2016/11/20/benzodiazepines-the-good-the-bad-and-the-ugly/)

[LilyPad1991]

I'm not a benzophobe. I find much of what is claimed about them online is ridiculous and benzophobia has almost become a cult complete with gurus and inane rituals…


Thanks so much for all this info. After a hideous night of wave upon wave of adrenaline I finally took one last night. It took the edge off. I’m feeling very hopeless this morning, worried that I’ll never be myself again. Those 8 months of trying to taper off duloxetine felt like they were going so well but I’m concerned they were the biggest mistake of my life.


It’s day 16 back on 60mg and I feel horrendous.

[panic_down_under]

I'm concerned they were the biggest mistake of my life.

Very unlikely. But let's assume duloxetine doesn't work. It isn't the only AD, or necessarily the most effective. There is a very high probability that another AD will give a better result with fewer issues.


It's day 16 back on 60mg

You need to give it at least 6 weeks. It can take quite a while for these meds to kick-in and there are no shortcuts, unfortunately. :sad:

>and I feel horrendous

In what way?

[LilyPad1991]

Very unlikely. But let's assume duloxetine doesn't work. It isn't the only AD, or necessarily the most effective. There is a very high probability that another AD will give a better result with fewer issues.

I know you’re right but I just want this episode to be over. I’m so tired and scared. I don’t want to go through the trial of trying to find another medication and I’m scared of trying to come off duloxetine because it’s an absolute pig to stop taking.




You need to give it at least 6 weeks. It can take quite a while for these meds to kick-in and there are no shortcuts, unfortunately. :sad:

Thank you: I will stick with it, I know it’s early days and I know it’s common for SNRIs in particular to worsen anxiety before it gets better. I’m just impatient and it’s been a long time since I’ve had to deal with anxiety like this. I haven’t missed it! I wish I’d never even attempted to come off the drugs. I’ve potentially lost a good thing.



In what way?

I feel horrendous, especially in the morning, because of the rolling waves of adrenaline I’m having through the night. They’re exhausting and unpleasant and I really miss getting some decent sleep. When I’m tired I definitely ruminate more and ‘what if’ about everything. And the diazepam made me feel so bloody spaced out and it didn’t even stop the waves of adrenaline.

[panic_down_under]

I'm scared of trying to come off duloxetine because it's an absolute pig to stop taking.

The better way of dealing with it would be to do a slow cross taper to another AD.


I feel horrendous, especially in the morning, because of the rolling waves of adrenaline I'm having through the night. They're exhausting and unpleasant and I really miss getting some decent sleep. When I'm tired I definitely ruminate more and 'what if' about everything. And the diazepam made me feel so bloody spaced out and it didn't even stop the waves of adrenaline.

Did you tell your GP about the adrenaline surges? If so, I wonder why a beta-blocker wasn't prescribed? Blocking adrenaline surges is what they are best at.

[LilyPad1991]

The better way of dealing with it would be to do a slow cross taper to another AD.



Did you tell your GP about the adrenaline surges? If so, I wonder why a beta-blocker wasn't prescribed? Blocking adrenaline surges is what they are best at.



I’ve just come out of my appointment with my GP. She is a wonderful and supportive doctor and she had allotted me a long slot, I ended up having 45 minutes of her time to go through everything. We have a plan which does include propranolol and basically putting things in place to give me the chance to get some respite to allow duloxetine to work. She also addressed my ‘what iffing’ and catastrophising around duloxetine not working and explained what the next steps would be if that should become a problem although as she said (and you have said), there is no real evidence that that is a concern yet.

Thank you for getting back to me again and for being a voice of reason and support.

[panic_down_under]

We have a plan which does include propranolol and basically putting things in place to give me the chance to get some respite to allow duloxetine to work

Good! :)

[LilyPad1991]

Good! :)

Hey Panic Down Under,

I wanted to pop back to send my thanks again and provide a brief update in case anyone in the future sees our chat back and forth and needs some hope.

After about 3 and a half of weeks of really intense side effects from going back up to 60mg of duloxetine, the significant increase in anxiety abated and I am pretty much back to myself now. I can sleep! I can eat! I can drive without panic and walk my dogs without fear and just do normal things again. I ended up taking propranolol for about a week, which provided significant relief from the anxious surges. I was so utterly convinced that I would never be me again and yet here I am. So thank you for your kindness and support. I hope you’re well.

[panic_down_under]

After about 3 and a half of weeks of really intense side effects from going back up to 60mg of duloxetine, the significant increase in anxiety abated and I am pretty much back to myself now.

This is very good news, indeed!! :emot-cheering: :emot-dance:


So thank you for your kindness and support. I hope you're well.

You're most welcome. :)

I'm doing okay for an old bugger though if I was a horse I'd probably have been sent off the the knackery a long time ago. :scared15: :winks:

[LilyPad1991]

Hi Panic Down Under!

How’re you doing? I hope you’re well.

I’m back again to pick your brain if you have the time so spare. I’ve been doing really well on duloxetine, pretty much back to normal. Lots of the usual life stresses and I’ve been coping well. Last week was especially busy and tiring and then on Friday I started my Masters - I’m doing a 4 year course to qualify as a Psychotherapist here in the UK. I hadn’t really thought much about the first long weekend of training beforehand but it was very intense emotionally and I’ve been feeling quite anxious, with the churning stomach and jittery chest that are so familiar to me as anxiety symptoms. I’m scared I’m going to ‘relapse’ because I’m still on my 60mg but the anxiety is ‘breaking through’. Do you think I’m overthinking it? I’m very aware that I have work to do on exploring my relationship with anxiety but right now I just could do with some wisdom.

One other thing I have thought - I’m currently taking a different duloxetine generic, one that I’ve never been on before. I know that we’re told that one generic is the same as another but that hasn’t always been my experience and I’m wondering if that is potentially contributing to my current experience. What do you know about this?

Thank you so much, as always 😊

[panic_down_under]

How're you doing? I hope you're well.

I'm doing okay. Thanks for asking. We've had a long dark, cold winter down in my part of Oz which was starting to get me down, but spring has finally put in an appearance. :)


I'm back again to pick your brain if you have the time so spare.

Time I have to spare, brain not so much. :winks:


I'm doing a 4 year course to qualify as a Psychotherapist here in the UK.

Ah, physician heal thyself.



I hadn't really thought much about the first long weekend of training beforehand but it was very intense emotionally and I've been feeling quite anxious, with the churning stomach and jittery chest that are so familiar to me as anxiety symptoms. I'm scared I'm going to 'relapse' because I'm still on my 60mg but the anxiety is 'breaking through'. Do you think I'm overthinking it?

Possibly. ADs can't protect us from all the stresses of life, or at least they shouldn't. We still need to laugh and cry. The stress should begin to ease as you adapt to the new experiences. If it does get overwhelming then you may need a dose increase, but I'd hold off for a week or two to see if things calm down. It would take some weeks for the higher dose to begin making a difference anyway by which time you're likely to be past the initial stresses. The important think is to accept that this is coming from the life changes and not that the old foe is dragging you back.


I'm very aware that I have work to do on exploring my relationship with anxiety but right now I just could do with some wisdom.

Oh, I could use some of that myself. It seems to be a very rare commodity in this crazy world we're living in these days.


I know that we're told that one generic is the same as another but that hasn't always been my experience and I'm wondering if that is potentially contributing to my current experience. What do you know about this?

It doesn't happen as often as it is claimed, but it does happen. If there were no other changes in your life it would be a hypothesis definitely worth considering. However, I think the extra stress you're currently under is the more likely explanation.

[LilyPad1991]

Thank you so much for getting back to me 😊



I'm doing okay. Thanks for asking. We've had a long dark, cold winter down in my part of Oz which was starting to get me down, but spring has finally put in an appearance. :)

Those long, dark days can be quite miserable can’t they! We’re heading into Autumn now and it’s suddenly got quite cold.



Possibly. ADs can't protect us from all the stresses of life, or at least they shouldn't. We still need to laugh and cry. The stress should begin to ease as you adapt to the new experiences. If it does get overwhelming then you may need a dose increase, but I'd hold off for a week or two to see if things calm down. It would take some weeks for the higher dose to begin making a difference anyway by which time you're likely to be past the initial stresses. The important think is to accept that this is coming from the life changes and not that the old foe is dragging you back.


I just wasn’t expecting to have such a reaction, so it came as quite a surprise. I’ve been so well and it’s scared me a bit to be reminded of those physical symptoms of anxiety. I’m also worried by the prospect of a potential dose increase, since going back up to 60mg caused such havoc. I have in the past occasionally gone up to 80 or 90mg with success but I’m more cautious now after the experiences of earlier in the year. I did speak to my GP, who is brilliant, and she said the same as you really, about taking some time to level out after a busy time and some intense experiences. I am just worried, which is hardly surprising 😂 The GP did remind me that I have 10mg propranolol tablets to help with the physical symptoms, if I want to use them again whilst I get through this ‘blip’. I know it’s silly but to me, that’s like accepting I’m not 100% and I don’t want to be unwell again. Anxiety really is awful.


I have been able to soothe myself by walking outside and doing yoga but I just so don’t want these physical symptoms of anxiety at all, ever. Can I ask, do you ever still get ‘flare ups’ of anxiety symptoms? I seem to recall you’ve been on your medication for a long time.



It doesn't happen as often as it is claimed, but it does happen. If there were no other changes in your life it would be a hypothesis definitely worth considering. However, I think the extra stress you're currently under is the more likely explanation.

This is interesting, thank you. I have my next prescription now and it’s a brand I’ve used before so it’s not really a concern now anyway. And as you said, the extra stress is a more likely culprit.


Thank you again for your reply. It is so helpful having the insight and knowledge of someone who knows what this is like!

[panic_down_under]

I'm also worried by the prospect of a potential dose increase, since going back up to 60mg caused such havoc. I have in the past occasionally gone up to 80 or 90mg with success

Of citalopram? The maximum recommended dose is 40mg/day and while most without cardiovascular problems could probably take the original recommended maximum 60mg without significant issues 80-90mg is well into the red zone.


The GP did remind me that I have 10mg propranolol tablets to help with the physical symptoms, if I want to use them again whilst I get through this 'blip'. I know it's silly but to me, that's like accepting I'm not 100% and I don't want to be unwell again. Anxiety really is awful.

Anxiety and depression are the emotional manifestations of a physical brain dysfunction caused by high stress hormone levels atrophying parts of the two hippocampal regions. It is essentially a type of auto-immune disorder which is why they often worsen when the immune system is in overdrive fighting an infection. If you had say rheumatoid arthritis and it flared up would you have the same feelings?


Can I ask, do you ever still get 'flare ups' of anxiety symptoms? I seem to recall you've been on your medication for a long time.

I haven't had a full blown panic attack in many years, possibly not this century. But I do occasionally have lesser episodes, racing heart, vertigo, sudden dry mouth, etc. Fortunately, these don't last long, maybe a minute or so and I rarely get more than 3-4 a year. I've looked for a pattern, but if there is one it's alluded me.

[LilyPad1991]

Of citalopram?

No, sorry, I’m on duloxetine. I think our conversation started on someone else’s thread that was originally about citalopram.


Anxiety and depression are the emotional manifestations of a physical brain dysfunction caused by high stress hormone levels atrophying parts of the two hippocampal regions. It is essentially a type of auto-immune disorder which is why they often worsen when the immune system is in overdrive fighting an infection. If you had say rheumatoid arthritis and it flared up would you have the same feelings?

I wouldn’t. I do also have endometriosis, which no one fully understands yet but is potentially a kind of auto-immune disorder, and I feel far more comfortable taking any necessary medications for that. What I’m struggling to wrangle with is why did this anxiety come on so suddenly, triggered by what seems to have been, tiredness, stress and then the intense emotional experience of my first training weekend? On Thursday I was fine. On Friday, I gradually seemed to slide downhill. I know there is something to be said of becoming hyper aware of physical anxiety symptoms, which I know I do, as much as I try to divert and deflect away from them.



I haven't had a full blown panic attack in many years, possibly not this century. But I do occasionally have lesser episodes, racing heart, vertigo, sudden dry mouth, etc. Fortunately, these don't last long, maybe a minute or so and I rarely get more than 3-4 a year. I've looked for a pattern, but if there is one it's alluded me.

That’s impressive! 😍

[panic_down_under]

What I'm struggling to wrangle with is why did this anxiety come on so suddenly, triggered by what seems to have been, tiredness, stress and then the intense emotional experience of my first training weekend? On Thursday I was fine. On Friday, I gradually seemed to slide downhill.

I'd have been surprised if you hadn't had a reaction. You were already tired and stressed before you got hit with intense emotions. That would also have triggered a reaction in the others on the course who don't have an anxiety disorder. The difference is they would have accepted the symptoms were a natural reaction to the stress they were under and not become fixated on them, or doubted their ability to cope and rebound. They would have seen it as a normal response, you perceived it as abnormal. How we frame such experiences matters.


I know there is something to be said of becoming hyper aware of physical anxiety symptoms, which I know I do, as much as I try to divert and deflect away from them.

The propranolol may damp down some of the physical effects.

[LilyPad1991]

I'd have been surprised if you hadn't had a reaction. You were already tired and stressed before you got hit with intense emotions. That would also have triggered a reaction in the others on the course who don't have an anxiety disorder. The difference is they would have accepted the symptoms were a natural reaction to the stress they were under and not become fixated on them, or doubted their ability to cope and rebound. They would have seen it as a normal response, you perceived it as abnormal. How we frame such experiences matters.

My therapist said exactly this today too, thank you for your wisdom! It's a really interesting concept, that I perceived the symptoms as abnormal. That is absolutely 100% what happened. I am just impatient to be back to my equilibrium though and I also feel impatient with all the various pieces of teaching that talks about 'acknowledging your anxiety and doing stuff anyway'. I understand it but the other side of my brain is saying, 'but I don't bl**dy want anxiety at all! I just want to be normal!'




The propranolol may damp down some of the physical effects.

I shall keep the propranolol for if I feel I really need it. I just feel generally quite sensitised after the emotional onslaught but I can soothe myself with breathing, yoga, dog cuddles etc etc. And I really, really appreciate your kindness, once again :)

[panic_down_under]

My therapist said exactly this today too,

:ohmy: I get concerned when the professionals agree with me. Where did I go wrong?! :winks:


I shall keep the propranolol for if I feel I really need it. I just feel generally quite sensitised after the emotional onslaught but I can soothe myself with breathing, yoga, dog cuddles etc etc.

Cool, but don't be a martyr for the sake of some ideal of purity by not taking a supposedly easy way out. There isn't any such thing. All that white-knuckling through the bad times does is reinforce the disorder. Plus, it isn't as if someone is handing out gold stars for bravery. So do what you need to do to get through the day with the minimum of trauma.