Stabilisation v needing higher dose

[apm]

Hi all,

I am just coming to the end of week 4 switching to Sertraline from Citalopram (which stopped working for me).

Week 1 was bad- poor sleep, lots of anxiety
Week 2 was worse- very high anxiety alot
Week 3 calmed down a bit, anxiety still there, but more background
Week 4 seems to be getting worse again- days with intrusive anxiety, some good days, some bad. Sleep is suffering again, too, to some extent.

I am taking 50mg daily, in the morning. Anxiety seems to be worse in the afternoon/ evening, tailing off towards bedtime.

I know that this medication takes 4-6 weeks to stabilise, but I am wondering if this pattern is more about my needing to increase the dosage to deal with my anxiety, or just the tail end of stabilisation?

Any thoughts welcome!

TIA,

Alex.

[panic_down_under]

am taking 50mg daily, in the morning. Anxiety seems to be worse in the afternoon/ evening, tailing off towards bedtime.

You could try switching to taking it in the evening, Alex. In theory this shouldn't make any difference as once plasma levels stabilize which takes about 5 days for sertraline they don't vary much across 24 hours, but in practice sometimes it does.

I know that this medication takes 4-6 weeks to stabilise,

It's not about stabilising, but that it takes time for the brain cells that the AD stimulates into growth take weeks to grow. The new cells and the connections they form create the therapeutic response, not the med directly. ADs typically kick-in between 4-12 weeks with most beginning to see positive signs at around 6 weeks, however, as this isn't your first AD it may take a little longer.

but I am wondering if this pattern is more about my needing to increase the dosage to deal with my anxiety, or just the tail end of stabilisation?

A good question. It could be either, however, my money is on the dose being inadequate. 50mg is the recommended minimum effective dose with most need to take 100-150mg for optimum results and given a previous SSRI pooped-out I doubt 50mg is going to work for you. Also as I understand it you were on 40mg citalopram which is roughly equivalent to about 100mg sertraline (AD equivalence isn't an exact science so some dose tuning may be required).

[apm]

Many thanks for your reply, p_d_u.

I am speaking to the doc next week about potential dose increase. By then, this dose should be impacting if it's going to, so that would be a good time to make that decision?

If I do need to increase the dose, are the side-effects bad going from 50mg to 100mg?

Thanks again,

Alex.

[panic_down_under]

If I do need to increase the dose, are the side-effects bad going from 50mg to 100mg?

Increased side-effects are by no means a given, but if you expect the worst you're likely to get it, unfortunately. An anxious mind off the leash can produce far worse symptoms than any med.

I suggest you take 75mg for a week before increasing to 100mg, but clear that with your GP first.

[apm]

Many thanks, PDU. I spoke to the doc, who has upped to 100mg, starting now.

I remember no side effects at all going from 20mg - 30mg - 40mg on the Citalopram, so hopefully it won't be too bad.

To be honest, things are not great now, so hopefully won't be much worse!

Thanks again,

Alex.

[panic_down_under]

I spoke to the doc, who has upped to 100mg, starting now.

Did you ask about only increasing to 75mg for a week, Alex, and if so what was the response?

I remember no side effects at all going from 20mg - 30mg - 40mg on the Citalopram, so hopefully it won't be too bad.

It is possible that the symptoms will be no worse. It all comes down to individual biology.

[apm]

Many thanks again- I feel I have a consultation with you!

By the time I'd received your previous response, the doc had already prescribed 100mg, and I'd taken it, so I missed the 75mg boat...

Anxiety was higher yesterday, and very edgy. Dipped by bedtime (which has been my pattern).

I took a Zopiclone and slept extremely well. Woke with no anxiety.

Still early, but anxiety is low.

Fingers crossed for a relatively soft landing...

[panic_down_under]

Fingers crossed for a relatively soft landing...

Indeed. There's a good chance that it will be. Despite the impression given by support groups like NMP, most have few significant side-effects.

[matrix123]

I'm in a similar position. I've been on and off SSRIs a few time (always thought I would not need them when feeling better). Initially I was on Escitalopram, while in August 2020 started Sertraline (100 mg). I was feeling better and got off them in April 2021. Unfortunately, I had to start it again in early February. I did start with 25mg for one week, 50mg for another week and then 100mg. Side effects have been bad, but I did expect it. However now I've been 3 weeks on 100mg and doesn't see to see any improvements. I'm wondering if I should go up to 150mg? Or is it better to wait 2-3 more weeks and then decide?

Thanks

[panic_down_under]

I'm in a similar position. I've been on and off SSRIs a few time (always thought I would not need them when feeling better). Initially I was on Escitalopram, while in August 2020 started Sertraline (100 mg). I was feeling better and got off them in April 2021. Unfortunately, I had to start it again in early February.

Given this is your third time on ADs I think you should think about staying on them permanently. Not only will this avoid the initial side-effects trauma, but ADs seem to become progressively less effective each time they are stopped and restarted often requiring higher doses to achieve previous levels of control. They may also produce more severe and/or different initial side-effects and take longer to kick-in too.

Two studies, Amsterdam JD, 2016 and Amsterdam JD, 2009, found the likelihood of antidepressants working after each restart drops by between 19-25% (see also: Bosman RC, 2018; Amsterdam JD, 2009; Leykin Y, 2007; Paholpak S, 2002).

I did start with 25mg for one week, 50mg for another week and then 100mg. Side effects have been bad, but I did expect it. However now I've been 3 weeks on 100mg and doesn't see to see any improvements.

You have only been on a therapeutic dose for 4 weeks so it is way too early to draw any conclusions. ADs typically take 4-12 weeks to kick-in with most beginning to see improvements from about 6 weeks. Given your history you're more likely to see results toward the longer end of the range.

I'm wondering if I should go up to 150mg? Or is it better to wait 2-3 more weeks and then decide?

How much were you taking when last on sertraline?