Sticking with Sertraline?

[JamieRR6]

Hi guys,

I started sertraline 7 days ago, as recently my general anxiety has worsened to the point of verging on depression/breakdown. It was prescribed to me years ago, but I was always very anti-medication.

I am on day 7 of 25mg, and to be honest this week has been unbearable. I know heightened anxiety is a known side effect at first, but I have found myself in a perpetual stake of sheer panic and anxiety. It has made my OCD intrusive thoughts get far worse, leading to more anxiety etc. I’ve found myself in crisis several times, having to reach out to helplines to get me through the week.

I have been in constant communication with my GP, who thinks I should get up to the 50mg therapeutic dose now and hopefully see the positives of the medication start working. I am quite anxious about how the increase will go, with this past week in mind.

Did anyone find the change from 25-50mg as severe as 0-25mg?

Since starting sertraline, I have reached out to a lot of services (referred for therapy etc.), family and friends and even work for support. This is something I have never done before, and when talking things through I feel at my best. The thing I am struggling to decide, is whether it is worth me stopping the tablets and trying to get through this with the support I have now built up, and if this doesn’t work maybe trying the tablets in the future.

The flip side is, I have had to take some time off work (which I have never done before), so do wonder if it is worth persevering with the tablets to see if I get any benefit from them. It’s such a tricky decision!

Does anyone regret not trying to utilise natural means for getting through their illness before opting for medication?

Thanks very much for any replies in advance!

[panic_down_under]

I started sertraline 7 days ago, as recently my general anxiety has worsened to the point of verging on depression/breakdown. It was prescribed to me years ago, but I was always very anti-medication.

Anti med for psych meds, or generally?

I am on day 7 of 25mg, and to be honest this week has been unbearable. I know heightened anxiety is a known side effect at first, but I have found myself in a perpetual stake of sheer panic and anxiety. It has made my OCD intrusive thoughts get far worse, leading to more anxiety etc. I’ve found myself in crisis several times, having to reach out to helplines to get me through the week.

I have been in constant communication with my GP, who thinks I should get up to the 50mg therapeutic dose now and hopefully see the positives of the medication start working. I am quite anxious about how the increase will go, with this past week in mind.

Antidepressants, especially the SSRIs and SNRIs, can produce a range of side-effects at the beginning. However, not all may necessarily be down to the med itself, but be generated by the mind. Believe you will suffer greatly and an anxious mind is very capable of producing your worst nightmare.

Has your GP offered to prescribe something to help ease the anxiety until the side-effects diminish? If not, ask. White-knuckling through this is counterproductive.

Did anyone find the change from 25-50mg as severe as 0-25mg?

Instead of increasing the dose by 25mg maybe take only an extra 12.5mg for the first week. You should get your GP's okay for this.

Does anyone regret not trying to utilise natural means for getting through their illness before opting for medication?

If by natural means you mean therapy, then the cognitive/behavioural (CBT, REBT, etc) and mindfulness therapies can be very effective. The main problem is access. Waiting times can be long in many places.

Anxiety disorders (also depression) are the emotional symptoms of a physical brain malfunction, atrophy of parts of the two hippocampal regions of the brain caused by high brain stress hormone levels, mostly of cortisol, killing hippocampal brain cells and inhibiting the growth of new ones (see also (PDF)). Both antidepressants and the therapies stimulate the growth of new neurons. It is these neurons and the connections they forge which produces the improvement in mood, not the treatments directly.

[JamieRR6]

Anti med for psych meds, or generally?

To be honest probably medication in general. I was very much under the old thinking style of ‘natural is best’, however must admit this has not worked for me for the past several years. I am very much a hypochondriac so although I know SSRI’s are meant to be safe long term, I do worry about being reliant on them and them causing health issues down the line.

Antidepressants, especially the SSRIs and SNRIs, can produce a range of side-effects at the beginning. However, not all may necessarily be down to the med itself, but be generated by the mind. Believe you will suffer greatly and an anxious mind is very capable of producing your worst nightmare.

Yeah that’s fair enough. I do think there will be an anxious element there, and I’d be lying to say I wasn’t in a bad state before taking them. It’s just it feels like it’s taken me from being a (just about) functioning person to a mess in the space of a week, although as you say I am sure this could partly be due to spiralling mental health.

Has your GP offered to prescribe something to help ease the anxiety until the side-effects diminish? If not, ask. White-knuckling through this is counterproductive.

He gave me some Diazepam 2mg to try if required. I took it twice which did help with the acute severe panic attacks at the time, however I am conscious of the dangers or Benzos so keen not to develop a dependance. It also doesn’t help with the general sense of panic/low mood/ irritability and OCD that has exacerbated recently.

Instead of increasing the dose by 25mg maybe take only an extra 12.5mg for the first week. You should get your GP's okay for this.

This is a good idea, although the tablets I have are already 50mg so wouldn’t be too easy without asking for some 25mg’s from the doctor.

If by natural means you mean therapy, then the cognitive/behavioural (CBT, REBT, etc) and mindfulness therapies can be very effective. The main problem is access. Waiting times can be long in many places.

Yeah you’re certainly right there. I’ve found the only thing that has helped me in the last few days is when I speak to someone (being online, crisis helplines, family). My normal coping mechanisms (reading, gaming, meditation, distraction techniques) have been rendered useless in helping me which has made this week so hard.

Anxiety disorders (also depression) are the emotional symptoms of a physical brain malfunction, atrophy of parts of the two hippocampal regions of the brain caused by high brain stress hormone levels, mostly of cortisol, killing hippocampal brain cells and inhibiting the growth of new ones (see also (PDF)). Both antidepressants and the therapies stimulate the growth of new neurons. It is these neurons and the connections they forge which produces the improvement in mood, not the treatments directly.

Thanks for the link! I do feel like I have learnt a lot about my mental health over the past week. It’s made me realise how I have been white knuckling my way through chronic anxiety now for years. It’s annoying as on paper I can see exactly why I feel like this - My life has changed quite significantly recently which impacts me, I have several other stressors, winter is always hard on me and some health concerns and work stress. Combine that with the heightened anxiety that often results when starting sertraline, it makes sense that I am so overwhelmed, anxious and run down. This does little to alleviate how I feel in the moment and to help me cope until hopefully the sertraline helps.

Thanks for replying PDU, reading through your previous replies in this thread has brought a lot of reassurance!

[Phill2]

Everyone is different but when my Dr put me on Sertraline and went through 6 weeks of hellish side effects even with 2 x 5mg Benzos twice daily.
The worst part was being tired all the time but unable to sleep.
I also gained 16kg in about 12 months while on 50mg.
I eventually talked my Dr into letting me cross taper onto 10 mg Lexapro and all is now good.
Even lost the 16kg without effort.

[panic_down_under]

although I know SSRI’s are meant to be safe long term, I do worry about being reliant on them and them causing health issues down the line.

There are many people who've been taking SSRIs pretty much continually for over 30 years with little evidence of harm. Whether you'll need them long-term only time will reveal. On a positive note SSRIs are mild anticoagulants which may reduce heart attack and ischaemic stroke risk, but may slightly increase it for the much less common haemorrhagic stroke. They may also reduce the risk of Alzheimer's Disease.

He gave me some Diazepam 2mg to try if required. I took it twice which did help with the acute severe panic attacks at the time, however I am conscious of the dangers or Benzos so keen not to develop a dependance.

The 'dependency' issue is much overblown and is unlikely to be a concern in the short time you're likely to need diazepam. A bigger problem is that benzodiazepines (BZDs) may significantly reduce the effectiveness of antidepressants by blocking hippocampal neurogenesis [1] so should ideally only be used to ease the initial increase in anxiety levels when starting ADs, for a while after AD dose increases for the same reason and thereafter only for occasional breakthrough anxiety.

BTW - 'fun' fact. You are already dependent on BZDs and have been since the womb. All creatures are as BZDs occur naturally in all the foods we eat [2]. Diazepam (Valium) and its metabolites and lorazepam (Ativan) seem particularly prevalent in plants. My guess is that benzodiazepines are a plant poison to which life, including Homo sapiens, have become so adapted to that we can no longer function without them.

While the quantities we get from food are small, they are not insignificant. Natural BZDs can reach pharmaceutical levels in patients with some liver diseases [3]. They may become so high that medical intervention is necessary [4].

This is a good idea, although the tablets I have are already 50mg so wouldn’t be too easy without asking for some 25mg’s from the doctor.

I can't remember how big sertraline tablets are, but a pill-cutter might be able to quarter a 50mg tablet with precision. There is no reason I can think of for your GP not to prescribe it in 25mg tablets if asked. He should have offered to do so when you began having problems. If you do try a pill-cutter make the first cut across the tablet score, i.e. at 90 degrees, and then use the score to line up the second cut.

Yeah you’re certainly right there. I’ve found the only thing that has helped me in the last few days is when I speak to someone (being online, crisis helplines, family). My normal coping mechanisms (reading, gaming, meditation, distraction techniques) have been rendered useless in helping me which has made this week so hard.

Diversion can only do so much. A big part of therapy is learning how to tackle the though processes which lead to anxiety taking control before they get out of hand.

Thanks for the link! I do feel like I have learnt a lot about my mental health over the past week. It’s made me realise how I have been white knuckling my way through chronic anxiety now for years. It’s annoying as on paper I can see exactly why I feel like this - My life has changed quite significantly recently which impacts me, I have several other stressors, winter is always hard on me and some health concerns and work stress. Combine that with the heightened anxiety that often results when starting sertraline, it makes sense that I am so overwhelmed, anxious and run down. This does little to alleviate how I feel in the moment and to help me cope until hopefully the sertraline helps.

Everyone has a breaking point. Apply enough pressure and most will eventually succumb. As it is about a quarter of the population will develop either an anxiety disorder, depression, or both at some time in their lives.

References:

[1]

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 | Full text)

Nochi R, Kaneko J, Okada N, et al. (2013)
Diazepam treatment blocks the elevation of hippocampal activity and the accelerated proliferation of hippocampal neural stem cells after focal cerebral ischemia in mice.
J Neurosci Res. Nov;91(11):1429-39 (Abstract)

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)

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 | Study full text)

Chen J, Cai F, Cao J, et al. (2009)
Long-term antiepileptic drug administration during early life inhibits hippocampal neurogenesis in the developing brain.
J Neurosci Res. Oct;87(13):2898-907 (Abstract)

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)

Stefovska VG, Uckermann O, Czuczwar M, et al (2008)
Sedative and anticonvulsant drugs suppress postnatal neurogenesis
Ann Neurol. 2008 Oct;64(4):434-45 (Abstract)


[2]
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)

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)

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) 194-202 (Abstract)

Kotz U, (1991)
Occurrence of "natural" benzodiazepines.
Life Sci;48(3):209-15 (Abstract)

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)

Wildman J, Ranalder U. (1988)
Presence of lorazepam in the blood plasma of drug free rats.
Life Sci. 43(15):1257-60. (Abstract)

Wildmann J. (1988)
Increase of natural benzodiazepines in wheat and potato during germination.
Biochem Biophys Res Commun. Dec 30;157(3):1436-43. (Abstract)

Wildmann J, Vetter W, Ranalder UB, et al (1988)
Occurrence of pharmacologically active benzodiazepines in trace amounts in wheat and potato.
Biochem Pharmacol. Oct 1;37(19):3549-59. (Abstract)

Sangameswaran L, Fales HM, Friedrich P, De Blas AL. (1986)
Purification of a benzodiazepine from bovine brain and detection of benzodiazepine-like immunoreactivity in human brain
Proc Natl Acad Sci U S A. 1986 Dec;83(23):9236-40. (Abstract | Full text - PDF)

[3]
Baraldi M, Avallone R, Corsi L, et al (2000) Endogenous benzodiazepines. Therapie Jan-Feb;55(1):143-6 (Abstract)

[4]
Als-Nielsen B, Gluud LL, Gluud C. (2004)
Benzodiazepine receptor antagonists for hepatic encephalopathy.
Cochrane Database Syst Rev. 2004;(2):CD002798. (Abstract)

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)
[Note: no benzodiazepine synthesizing gut flora has been isolated and they almost certainly don't exist in humans]