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Thread: Advice needed

  1. #31
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    Jan 2017
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    Re: Advice needed

    Quote Originally Posted by Jo79 View Post
    The first AD I took was Citalopram - 20mg in 2008 and then up to 60mg in 2011.
    So the dose was progressively increased because anxiety/depression kept coming back?

    but was switched over to amitriptyline in 2013 while trying for a baby.
    Which probably wasn't actually necessary. Paroxetine (Paxil) is the only SSRI with clear evidence for increasing birth defects. How much amitriptyline did you take and how effective was the med?

    When I went back on Citalopram a third time due to PND in 2015 the side effects were even worse
    Which is quite common when returning to a previously taken AD. A higher dose than before to achieve the same level of response is also often needed.

    and I was switched to 100mg sertraline. This was increased to 200mg in 2017 after another bout of anxiety and depression and 15mg mirtazapine was added.
    This is where things start going off the rails, imho. If an AD isn't capable of adequately containing the disorder/s it's prescribed for even at the maximum recommended dose then what is the point of continuing to take it while adding more and more supplementary meds? (The exception to this may be buspirone (Buspar) which has a pretty good track record for boosting the effectiveness of serotonergic ADs, and reinvigorating those that have pooped out.) All the 15mg mirtazapine was capable of doing is sedating the anxiety into submission to some extent, but it doesn't last.

    Starting January 2019 I was still on 200mg sertraline and 15mg mirtazapine but started getting anxiety and depression again. GP increased mirtazapine to 30mg mid February.
    The sedation eased allowing the anxiety and depression symptoms to reassert themselves.

    I started seeing the private psychiatrist beginning of March and she changed sertraline to escitalopram beginning of April and continued with 30mg mirtazapine. This combo kicked in within two weeks and I felt great for two months then after a night out drinking too much in mid June my anxiety and intrusive thoughts came back. Psychiatrist increased escitalopram to 30mg at the end of June
    Sounds like you are no longer responding to SSRIs, even at doses well above the recommended maximum.

    and then changed to 75mg venlafaxine mid July increasing to 150mg after 1 week. Increased to 225mg a few weeks later at the end of August and then 25mg quetiapine was added at the start of October. This was gradually increased to 200mg by mid December and by then I started seeing the NHS psychiatrist. After 1 week on 200mg quetiapine she increased my venlafaxine to 300mg. After a couple of weeks I started feeling OK (could have been the quetiapine increase kicking in?) and after 3 weeks the venlafaxine was increased to 375mg.
    And now there is the same pattern, the primary med isn't working so start chucking more and more meds into the pot in the hope something will work. Sigh.

    This is just more evidence that you're no longer responding to SSRIs (despite what it says in the label, venlafaxine is really only a SSRI even at the maximum dose) and it seems you're no longer responding to the antihistamine driven sedation of quetiapine and mirtazapine.

    Now the OCD intrusive thoughts are through the roof, I feel exhausted with all the adrenaline rushes and Iím just at the end of my tether not knowing whether I should give it more time or if this is just all too much and should reduce something. Iíve got a constant grief-like ache in my chest and Iíve just had enough.

    I would say OCD is my main issue as I suffer with intrusive thoughts and constantly seeking reassurance from my worries but non-stop googling. Depression is also there but only mildly and I think it has improved. I am functioning and managing to do every day stuff but things arenít getting done due to the amount of time I spend reassurance seeking online
    OCD is by hardest of the anxiety disorders to treat often being resistant to both meds and therapy. The two ADs with the best OCD track record are the SSRI fluvoxamine (Luvox) and the TCA clomipramine (Anafranil). IMHO, clomipramine is the better choice because fluvoxamine interacts with many medications which can be make life complicated if there are other health issues, plus in your case SSRIs don't seem to be that effective now, and may not ever have been. A good result from the TCA amitriptyline you took a few years ago might be a pointer to clomipramine prospects.

    Unless there is a significant improvement in the next month, or so from the 375mg venlafaxine I think it should be dumped, no point taking such a large dose (or arguably even a small one) for no gain and replaced with clomipramine via an initial reduction in the venlafaxine dose and then a gradual cross-taper. Another possibility is replacing the quetiapine and mirtazapine with one of the noradrenergic/norepinephrinergic ADs, nortriptyline, lofepramine, or desipramine to essentially create a bespoke SNRI, although venlafaxine isn't the best SSRI to do this with, and especially not at 375mg.
    __________________

    The opinions expressed above are based on my observations and, where applicable, interpretation of cited data and are general in nature. Consult your physician before acting on anything stated.

  2. #32
    Join Date
    Jun 2014
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    9,147

    Re: Advice needed

    Just how easy would it be to come off 375mg venlafaxine though?

  3. #33
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    Re: Advice needed

    Looks as though there are supply problems with anafranil in the UK though and it shouldn't be prescribed alongside ven.

  4. #34
    Join Date
    Mar 2019
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    Re: Advice needed

    WRT to citalopram, I was taking 20mg for two years but then stopped cold turkey as I was feeling fine and kept forgetting to take it anyway. I didnít know at the time that this is a big no no. I relapsed badly a couple of months later and went back on it but gradually titrated up to 60mg as the original 20mg wasnít as effective, obviously because I messed around with it so much. However, the 60mg worked very well for me and I weaned off this under the proper direction of my GP with no problems at all.

    WRT amitriptyline - after weaning off Citalopram I was put on the minimum dose, 10mg - not even therapeutic for anxiety and depression Iíve been told. I suppose you could say I had fully recovered after the Citalopram but I just wasnít comfortable with being completely med free. Anyway, I managed to go two years on this tiny dose until I had my son and the PND hit me.

    Maybe Iím not responding to SSRIs anymore but it could just be that Iím not giving them enough time. I remember being on the Citalopram it wasnít until around week 8 that I felt better the first and second time, Sertraline took 6 weeks and maybe if I had realised it was just a blip on the escitalopram and carried on it might have settled.

    Iím going to keep going on the ven for now, the prospect of coming off terrifies me but itís good to know there are other options, even if it takes another few months to get there. Thanks PDU for your advice xx

  5. #35
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    Jan 2017
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    Re: Advice needed

    Quote Originally Posted by Jo79 View Post
    WRT to citalopram, I was taking 20mg for two years but then stopped cold turkey as I was feeling fine and kept forgetting to take it anyway. I didnít know at the time that this is a big no no.
    Even most psychiatrists are still not aware of the dangers of missing doses, stopping CT, etc, despite the evidence, both from studies and anecdotal from patients.

    However, the 60mg worked very well for me and I weaned off this under the proper direction of my GP with no problems at all.
    This changes my thinking a little. Citalopram might still work, the problem being that 40mg is now the recommended maximum dose because of fears about its potential affect on the heart at greater doses which may be overblown, but which a GP probably won't want to exceed and should 60mg prove inadequate it is unlikely any GP or psychiatrist would be prepared to go higher. If buspirone (Buspar) were more readily available in the UK than it appears to be taking 40mg + 20-30mg buspirone could be worth a shot.

    WRT amitriptyline - after weaning off Citalopram I was put on the minimum dose, 10mg - not even therapeutic for anxiety and depression Iíve been told. I suppose you could say I had fully recovered after the Citalopram but I just wasnít comfortable with being completely med free. Anyway, I managed to go two years on this tiny dose until I had my son and the PND hit me.
    Anxiety and depression aren't static disorders, they wax and wane over cycles that can last months and years. I think you got lucky and entered the waning part of the cycle. While sub therapeutic dosing can lead to the brain no longer responding to the AD, the tricyclics seem to be more resistant than SSRIs and SNRIs.

    Maybe Iím not responding to SSRIs anymore but it could just be that Iím not giving them enough time. I remember being on the Citalopram it wasnít until around week 8 that I felt better the first and second time, Sertraline took 6 weeks and maybe if I had realised it was just a blip on the escitalopram and carried on it might have settled.
    One of the problems with ADs is that doctors often claim ADs will begin working within 2-4 weeks and will either start ramping up the dose, or switch patients to another AD if they haven't responded. Those that do respond are almost always getting the benefit of the placebo effect, not having a genuine response until a few weeks later, but this perpetuates the 2-4 week myth. ADs work by stimulating the growth of new brain cells and it is the new cells and the connections they forge which produce the therapeutic response and brain cells don't grow overnight. They take about 7 weeks to reach full maturity, however, they may begin having a positive effect a little earlier with many beginning to see improvement at 5-6 weeks. But it can take up to 12 weeks for some.

    Iím going to keep going on the ven for now, the prospect of coming off terrifies me but itís good to know there are other options, even if it takes another few months to get there.
    Cool. There are many more options should they be needed.

    BTW - ask your doctor about taking N-Acetyl-Cysteine (NAC) supplements for OCD.

    A number of small scale studies have found NAC can reduce OCD intrusive and compulsive thought patterns and also boost the effectiveness of antidepressants for OCD and other OCD spectrum disorders. There is a large scale multinational study currently underway to test this. NAC is generally a safe supplement with few side-effects. It is mostly used medically to protect the liver in cases of paracetamol, aka acetaminophen, overdose and has other medical uses. Doses of 1,800-3,000mg/day taken in 3 divided doses seems to work (start with one dose per day of around 500-600mg and increase by the same amount every 2-3 days to avoid triggering diarrhoea). NAC is best taken on an empty stomach about an hour before meals.

    HOWEVER, be aware that a study found NAC (also Vitamin E) may increase the risk of lung cancer in smokers, or those with some specific lung diseases (note, it doesn't cause lung cancer, only maybe reduces the ability of the immune system to detect and destroy existing cancerous cells). This finding has been the subject of much debate because there are many other studies showing NAC protects against lung cancer so it is probably not the final word on the subject.

    Don't take it without getting advice from your GP, or psychiatrist. While it can be beneficial for asthmatics with fluid build up in lungs, it may cause shortness of breath in some, so caution is needed if you have asthma. It is contraindicated for those taking nitroglycerin, vitamin K and some blood pressure meds.
    __________________

    The opinions expressed above are based on my observations and, where applicable, interpretation of cited data and are general in nature. Consult your physician before acting on anything stated.

  6. #36
    Join Date
    Mar 2019
    Posts
    159

    Re: Advice needed

    I have to admit that I already have a supply of NAC after seeing a previous post of yours about it . I’ve not been taking it religiously as I wasn’t completely convinced it would help and was only taking one 600mg a day if I remembered. I’ve doubled the dose over the last few days but will double check with my psychiatrist when I see her next week and increase it to 1800mg if she agrees .

    I too find it incredibly frustrating when doctors suggest improvements after only a couple of weeks. Every time i’ve increased or added something and have asked the question I’ve always been fobbed off with ‘you should start feeling better in a couple of weeks’. Even the psychiatrist I was seeing privately who is a Professor of psychiatry and also the lead psychiatrist at my local NHS health authority was insistent that 2-4 weeks would be enough time

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