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 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 by hippocampal neurogenesis as does exercise 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 - 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). 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% 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, 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). 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, 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 - 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). 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.

[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.