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Lexapro Decrease - Advice Needed


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okay, so the meds taken are in my signature at their current dosages.

i tapered over the past some eight months from 900mg/day of pregabalin to 50mg/day (i'm proud of myself) and stabilized, then i reduced escitalopram some 16 days ago from 25mg/day to 20mg/day. clonazepam has been left untouched at 4mg/day.

since decreasing escitalopram from 25mg/day to 20mg/day my basal level of anxiety has increased quite dramatically, but i'm quite hesitant to increase the amount ingested back to 25mg/day because the side effects are lessened on 20mg/day as one might imagine. @browri, sexual dysfunction is still present to a certain degree, but much less so.

i'm not super opposed to adding another medication, but i hope not to because i feel that that'd be excessive and the interactions between medications could be significant. i read @CrazyRedhead's recent interaction with her doctor on her clonazepam intake and it was worrying as my psychiatrist just retired and i'm to have an appointment with a new psychiatrist, referred to by my previous psychiatrist, on the 2nd of february.

we'll see what she has to say.

in the meantime, because it's been 16 days since i decreased escitalopram and i've deteriorated to an uncomfortable level of instability, albeit not a completely non-functional level, is there hope for improvement still or is this as good as it's going to get, placing aside idiosyncratic responses to medication reductions for the moment? the withdrawal symptoms, e.g. nausea, gastrointestinal upset, brain zaps, flu-like symptoms, etc., dissipated some four or so days ago, but the elevated anxiety remains. i've had two panic attacks within the past two weeks, one at work and one at home.

ideas? help?

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17 minutes ago, basuraeuropea said:

In the meantime, because it's been 16 days since i decreased escitalopram and i've deteriorated to an uncomfortable level of instability, albeit not a completely non-functional level, is there hope for improvement still or is this as good as it's going to get, placing aside idiosyncratic responses to medication reductions for the moment? the withdrawal symptoms, e.g. nausea, gastrointestinal upset, brain zaps, flu-like symptoms, etc., dissipated some four or so days ago, but the elevated anxiety remains. i've had two panic attacks within the past two weeks, one at work and one at home.

ideas? help?

In December 2021,  my pdoc decided to take me off my 10mg escitalopram, because he didn't like me being on  2 SSRIS--said it was too risky because of "serotonin syndrome"....

Anyway, over the course of about a month, I was off the escitalopram......My anxiety level went up at first while I was tapering, and anxiety was increased also when I was totally off........Now it's been almost a month since I've been off, and my anxiety level is still a bit elevated, although I don't have any other withdrawal symptoms.

So, I would say I still have an increased anxiety level, a month after being off, but my pdoc has not increased or added anything yet.

I guess only time will tell if the elevation in anxiety will go away for me.......

Do you plan on going any lower than 20mg of escitalopram?

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1 minute ago, CrazyRedhead said:

In December 2021,  my pdoc decided to take me off my 10mg escitalopram, because he didn't like me being on  2 SSRIS--said it was too risky because of "serotonin syndrome"....

Anyway, over the course of about a month, I was off the escitalopram......My anxiety level went up at first while I was tapering, and anxiety was increased also when I was totally off........Now it's been almost a month since I've been off, and my anxiety level is still a bit elevated, although I don't have any other withdrawal symptoms.

So, I would say I still have an increased anxiety level, a month after being off, but my pdoc has not increased or added anything yet.

I guess only time will tell if the elevation in anxiety will go away for me.......

Do you plan on going any lower than 20mg of escitalopram?

thanks for responding! no, i don't have plans for decreasing escitalopram further because it's been absolute hell just decreasing by 5mg and i've never been stable on less than the max fda-recommended amount of any ssri/snri. i thought i'd try to get rid of some of the side effects while maintaining stability and i've achieved the former but thus far not the latter. the only other ssri that i know will stabilize me is fluvoxamine, but changing from one ssri to another is extremely difficult for me.

the past year has been a nightmare with medication changes and tapering in general, so when my old psychiatrist proposed decreasing clonazepam over escitalopram i freaked out because of the difficulties i had with the pregabalin taper and previously the taper i finished to totally rid myself of nightly ambien/zolpidem usage. so, i decided to try to decrease the ssri and it's been about two weeks and i'm not stable. i'm calling the psych department today to speak with a nurse to see what she has to say. i really, REALLY do not want to increase escitalopram back to 25mg/day because the sides suck at such a high dose.

good to hear that your anxiety has decreased, albeit acknowledging that it's still there mildly. i would agree that 10mg of lexapro and 20mg of trintellix would put you at risk of serotonin syndrome, but it's probably not terribly likely given that there are a number of people on higher than fda-recommended max dosages of a single ssri/snri (me just a few weeks ago) and who don't develop serotonin syndrome. also, you were on that combo for a period of time with no issues, so your doctor is about reduction of potential harm, but that you hadn't developed serotonin syndrome on the two serotonergic drugs is a good indicator that you probably weren't going to.

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@basuraeuropea, if you're not planning to decrease any lower than 20mg, I would say there is definitely hope for you to stabilize out eventually on the 20mg.

I'm sorry you're having some distressing symptoms, though..........In my experience, it does take some time to adjust to a lower dose of a med, so this may be something you just have to ride out, until it gets better......IMO, I think it will get better for you in time.

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Just now, CrazyRedhead said:

@basuraeuropea, if you're not planning to decrease any lower than 20mg, I would say there is definitely hope for you to stabilize out eventually on the 20mg.

I'm sorry you're having some distressing symptoms, though..........In my experience, it does take some time to adjust to a lower dose of a med, so this may be something you just have to ride out, until it gets better......IMO, I think it will get better for you in time.

i hope so. thank you for responding, you're an angel!  i called the psychiatry department just a moment ago and left a message such that a nurse can call me back with advice. we'll see what she or he has to say.

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1 minute ago, basuraeuropea said:

i hope so. thank you for responding, you're an angel!  i called the psychiatry department just a moment ago and left a message such that a nurse can call me back with advice. we'll see what she or he has to say.

You're so welcome.....I know how bad anxiety can get, though......Hopefully the psych nurse will have some good advice for you....!!

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a nurse called me back and was kind enough to talk with me for a good 20 minutes about everything i'm experiencing. she said that she recommends that i continue with the 20mg of lexapro for another two weeks and if i fail to stabilize, she and the new doctor will come up with a plan to address the lingering anxiety without having to increase the ssri once more.

i'm currently in covid quarantine even though i tested negative per my employer's protocol, so being at home and doing nothing but staring at the walls lost in my thoughts has not at all been working in my favor. being out and about even while experiencing discomfort has been paramount to success during my taper(s) thus far. she mentioned health anxiety and that isn't something that is bothersome at all, but it definitely crossed my mind that not being around people with my mind distracted by routine daily activities has been detrimental to adjusting to the new dosage.

anyhow, i meet with the new doctor via zoom on the 2nd of next month and i'm to discuss all and then i'm supposed to check in again with her assistant nurse in two weeks. i'm hoping things go well for me.

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@basuraeuropea, glad to hear the nurse called you back and had some advice.....I think giving yourself 2 more weeks to stabilize is reasonable...

IMO, you should see at least some improvement by then, although I'm sure being in home quarantine isn't helping much.....How much longer will you be in quarantine?

I'm looking forward to hearing what your new pdoc has to say next week.....Please keep us informed.

Hopefully the new pdoc will have a good plan, and I hope things go well for you.....I'll be looking for your new posts...!!

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i mean, i left the house today because i needed groceries and also because my firm wanted me to provide for a PCR covid test even though at-home rapid tests have been negative. i won't be allowed back to the office until i receive those test results, which i was told would take between three and four days, so maybe monday?

i plan to take a little outing everyday, though -- to the grocery store, to the park, just going on a drive, etc., just to get out so that i'm not stuck home caught in thought loops.

i'll keep the thread updated. thank you so much for your support.

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  • 1 month later...

so i'm down to 3mg/day of klonopin from 4mg/day and while it hasn't been easy, it hasn't been horrific either as was the case with tapering lyrica. anyhow, my doctor suggested that i give consideration to lowering lexapro further. i have never done well on less than the maximum amount of an ssri/snri, and while i would love to be on a lower dose of lexapro, i think that that'd be setting me up for relapse and thus another compensatory/adjunctive medication would need to be added, and indeed hydroxyzine in a very small amount has been added to assist in the tapering of the benzodiazepine.

that said, hydroxyzine has its own side effects, notably related to cognitive functioning, and i'm hesitant to take more than 12.5mg/day as higher amounts lead to moderate cognitive impairment ostensibly because the drug is an anticholinergic.

she thought of then placing me back on mirtazapine for the millionth time, and granted the drug does work wonders, but it comes at a significant cost with harsh side effects, e.g., weight gain, lipid and cholesterol level elevation, and abnormal liver functioning due to the aforementioned.

anyhow, the antidepressants that have been most effective in controlling the anxiety-spectrum disorders for me have been paroxetine, duloxetine (combined with mirtazapine), and fluvoxamine. fluvoxamine is of particular interest because it doesn't seem as harsh in terms of its side-effect profile as paroxetine which truncates the emotional spectrum like no other, although it doesn't play well with other medications, particularly clonazepam which i'm currently still taking. because all of these medications are highly sedating (for me), they've worked well to quell anxiety. fluvoxamine has been particularly  sedating and i might be able to get by on less than the maximum dosage of 300mg/day but i'm hesitant as i work a full-time career and am entering a doctoral program in the fall. that said, i'm trying to figure this all out as, again, i enter a doctoral program in the fall.

i'm not terribly unstable, but i am plagued by negative side effects and while i'm not taking an exorbitant amount of medication, i'm trying to reduce to the bare minimum to remain stable.

so, the question really that i have for you all is, as i have my next appointment on the 28th of march, do you think it would be worthwhile to stop the clonazepam taper and focus on the antidepressant? or press on with the clonazepam taper in the hopes that the negative side  effects will dissipate? i'm not sure about the latter. i know that i have a large tolerance to the effects of the benzodiazepines after years of prescribed usage, however, i'm not quite sure that i've gained any tolerance to the sides of clonazepam. the ssri, on the other hand, has side effects that unremitting after years and years of usage. no tolerance issues with that class of medication.

as a final note, i'm fairly stable at present. i'm not perfect, but i'm not expecting perfection. i'm definitely functional if uncomfortable at times.

 

advice?

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2 hours ago, basuraeuropea said:

so, the question really that i have for you all is, as i have my next appointment on the 28th of march, do you think it would be worthwhile to stop the clonazepam taper and focus on the antidepressant? or press on with the clonazepam taper in the hopes that the negative side  effects will dissipate? i'm not sure about the latter. i know that i have a large tolerance to the effects of the benzodiazepines after years of prescribed usage, however, i'm not quite sure that i've gained any tolerance to the sides of clonazepam. the ssri, on the other hand, has side effects that unremitting after years and years of usage. no tolerance issues with that class of medication.

as a final note, i'm fairly stable at present. i'm not perfect, but i'm not expecting perfection. i'm definitely functional if uncomfortable at times.

 

advice?

Well, if I personally had the choice to either taper an antidepressant, or continue a benzo taper, I would opt for decreasing the antidepressant first.....But of course I'm not a doc..........Do you feel comfortable decreasing the lexapro?

You've already gone down 1mg of the clonazepam, so if she wants you to taper lexapro, I think I would just focus on the lexapro first, if it were me.

In my experience of tapering medications, I've found that tapering only one med at a time works the best for me

 

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1 hour ago, CrazyRedhead said:

Well, if I personally had the choice to either taper an antidepressant, or continue a benzo taper, I would opt for decreasing the antidepressant first.....But of course I'm not a doc..........Do you feel comfortable decreasing the lexapro?

You've already gone down 1mg of the clonazepam, so if she wants you to taper lexapro, I think I would just focus on the lexapro first, if it were me.

In my experience of tapering medications, I've found that tapering only one med at a time works the best for me

 

My only other thought - I could possibly see some pdocs (not necessarily specific to you) who might not want to go back up on the benzo if the continuing taper results in unacceptable anxiety. In other words, if you do go with the klonopin I’d make sure there is a specific backup  plan in place and that your doc would be willing to go back up if necessary 

maybe you could also set it up as a taper plus a PRN. I’ve had docs do this with me for other meds. Ex- reduce down to 2.5 but have 0.5 as a PRN. If a  certain amount of time goes by and your taking the PRN most days maybe that’s evidence that Continuing benzo taper isn’t the way to go 

Edited by Iceberg
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4 hours ago, CrazyRedhead said:

Well, if I personally had the choice to either taper an antidepressant, or continue a benzo taper, I would opt for decreasing the antidepressant first.....But of course I'm not a doc..........Do you feel comfortable decreasing the lexapro?

You've already gone down 1mg of the clonazepam, so if she wants you to taper lexapro, I think I would just focus on the lexapro first, if it were me.

In my experience of tapering medications, I've found that tapering only one med at a time works the best for me

 

yes, i think the doctor is flexible enough that she is willing to keep me on the benzodiazepine. i was the one who initiated the taper and she is willing to follow my pace.

the problem with decreasing lexapro is that i'll relapse. i was taking 25mg of lexapro prior to reducing to 20mg and did poorly so a small amount of hydroxyzine was needed. i'm trying to figure out how to reduce the lexapro as this drug has the harsher side-effect profile without relapsing and i don't see a way without adding another medication to offset the anxiety. which medication, though? i have no idea. i don't see another medication that can be added that won't cause further unwanted side effects or complicated polypharmaceutical interactions.

she really doesn't want me to taper anything -- she hinted that being on a benzodiazepine long-term isn't ideal and i was like, well, it's all risk:benefit when it comes to taking any medication which sort of shut her up. i'm the one who is sick of the side effects of these damn medications and so i am trying to slowly reduce this or that as much as possible and these were her suggestions in response to my desires.

i agree, changing one medication at a time is advisable and prudent.

 

edit: i would add that i wouldn't mind introducing mirtazapine again if i could somehow get around the insatiable hunger causing for immense weight gain. the drug is fantastic save for the weight gain. :(

3 hours ago, Iceberg said:

My only other thought - I could possibly see some pdocs (not necessarily specific to you) who might not want to go back up on the benzo if the continuing taper results in unacceptable anxiety. In other words, if you do go with the klonopin I’d make sure there is a specific backup  plan in place and that your doc would be willing to go back up if necessary 

maybe you could also set it up as a taper plus a PRN. I’ve had docs do this with me for other meds. Ex- reduce down to 2.5 but have 0.5 as a PRN. If a  certain amount of time goes by and your taking the PRN most days maybe that’s evidence that Continuing benzo taper isn’t the way to go 

i wholeheartedly agree with the taper plus PRN. i've failed a klonopin taper before and was placed right back on 4mg. now that i'm down to 3mg, i'm doing fairly well, so i don't foresee a reason to go back up to 4mg/day, although decreasing further might prove to be problematic.

thanks to both of you for your responses!

Edited by basuraeuropea
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5 minutes ago, Iceberg said:

Are you considering a switch to new ad or just a. Reduction ? 

i'm not at all opposed to a switch.  i know a reduction of the current AD i'm on will not work out for me given the response i had going from 25mg to 20mg/day and having to add hydroxyzine to stabilize me.

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Just now, Iceberg said:

i would just be concerned that a cross taper may bring the same issues as reducing the med, in the short term at least 

that's my concern too and why i haven't asked to change the AD. i think the only AD that i've been able to directly switch to without major issues was luvox/fluvoxamine because it's so damn sedating that there weren't many issues with anxiety increasing. i told my dr this and she said that because it is so sedating for me, excessively so even, that i might be able to get by taking less than the maximum fda-recommended dosage. i'm not sure.

after terrible instability for years, i'm understandably afraid to make drastic changes despite wanting to be in a better place or to take perhaps a more beneficial cocktail.

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23 minutes ago, basuraeuropea said:

terrible instability for years, i'm understandably afraid to make drastic changes despite wanting to be in a better place or

This is easily one of the most difficult parts of managing MI for me. Unfortunately, I’ve failed on so many meds that I often just have to accept the degree of shittyness 

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2 minutes ago, Iceberg said:

This is easily one of the most difficult parts of managing MI for me. Unfortunately, I’ve failed on so many meds that I often just have to accept the degree of shittyness 

i am in the same boat, but i'm trying.

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  • 3 weeks later...

so, i had an appointment with my psychiatrist yesterday and i commented that i both didn't like taking hydroxyzine AND escitalopram as well as not like the side effects of either drug when one medication might do the job of both more effectively at a lower dosage. she suggested a very slow cross-taper from escitalopram to paroxetine. i haven't started the cross-taper yet, however, she stated that it's better to undershoot final dosage than to overshoot due to potential side effects and risk:benefit ratio favoring benefit. i have done well on paroxetine before, stabilizing on 40mg/day of the drug, less than the equivalent dosage of 20mg/day of escitalopram currently being taken. i'm assuming that she chose paroxetine for this reason as well as it being anticholinergic which would cover some of what hydroxyzine does via its unique mechanism of action. she stated that ideally, the dosage she's aiming for is 30mg/day, although i really doubt that will cut it. she did mention adding an adjuctive medication to 30mg, if not 40mg should i not stabilize, although i have no idea what medication that would be and at present she doesn't either.

if this fails and i need 60mg/day of paroxetine, then i'll be no better off than i am now, so the next logical choice in her and my mind is fluvoxamine as that has also worked well, albeit with a ton of sedation and a ton of drug-drug interactions, particularly with clonazepam which she didn't seem too concerned about, but still she left it up to me, so i chose to try paxil first.

she also mentioned replacing pregabalin with oxcarbazepine but i pushed back on that idea because it's a drug that doesn't target the symptoms of the disorders that distress me most: the anxiety-spectrum disorders.

wish me luck and provide any insight should you have any!

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9 hours ago, basuraeuropea said:

 wish me luck and provide any insight should you have any!

I think a slow cross taper to paroxetine is a good first choice, given that it's worked well for you before........I've tried fluvoxamine before too, and it was very sedating for me as well.........I think your plan seems very reasonable. and I'm really hoping it works out...!!

I've never tried oxcarbazepine before, so I can't comment on that one.

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thank you @CrazyRedhead! i am apprehensive because of my history of severe instability, falling victim to the anxiety-spectrum disorders during medication changes. i also thought that perhaps she would be able to assist in finally removing the small amount of lyrica that i'm on that i've unable to do on my own or to assist in lowering klonopin further, but her go-to was paxil. i did write her with these concerns and she, as of yet, has not prescribed paxil (nor trileptal, which i've certainly never taken and which i thought was a strange choice), so we'll see how she responds. just the thought of the potential major instability has me anxious that's how afraid i am - a misstep with lyrica or klonopin is very easily corrected by going back up, but that isn't the case with an ssri where the condition may deteriorate and then take weeks/months to stabilize to a reasonable level once again.

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16 hours ago, basuraeuropea said:

thank you @CrazyRedhead

 I did write her with these concerns and she, as of yet, has not prescribed paxil (nor trileptal, which i've certainly never taken and which i thought was a strange choice), so we'll see how she responds. just the thought of the potential major instability has me anxious that's how afraid i am - a misstep with lyrica or klonopin is very easily corrected by going back up, but that isn't the case with an ssri where the condition may deteriorate and then take weeks/months to stabilize to a reasonable level once again.

Hmmm....Maybe your doc senses you are apprehensive about the switch to Paxil....I do certainly understand your fear of becoming destabilized during the switch.

When do you see her next?

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21 hours ago, CrazyRedhead said:

Hmmm....Maybe your doc senses you are apprehensive about the switch to Paxil....I do certainly understand your fear of becoming destabilized during the switch.

When do you see her next?

hi there! so yeah, i communicated with her via email about the apprehension and laid out the framework of my plan to reduce clonazepam further and to somehow eliminate the small bit of pregabalin that i'm still on. it's far easier to slowly chip away at clonazepam and remain rather stable than it is to do the same with an ssri as the ssri is really what's keeping the irrational thoughts that are typical of panic disorder and generalized anxiety disorder at bay. i also told her that a misstep in reducing clonazepam and/or pregabalin is very easily corrected and immediately felt by updosing to where i was and this is absolutely not the case with a misstep with a switch, change, or reduction with an ssri as it can take weeks to months for the damage to be undone having to rely on another medication to keep it together which is quite scary given my past history of instability.

i also told her that paroxetine, while effective in the past, has had some pretty severe emotional side effects that escitalopram does not have, e.g., an impactful truncation of the emotional spectrum, that i'd rather not deal with in addition to the sexual side effects. i instead stated that if there comes a time when i feel that it would not be wise to reduce clonazepam further and i feel the need for improvement, weighing the risks:benefits of switching ssris, then fluvoxamine may be the better choice as because it's super sedating, i might be able to stabilize on a lower dosage of the drug, i.e., not the max-equivalent dosage of 300mg/day that i'd normally jump to from 20mg/day of escitalopram.

she's quite understanding and is an advocate for what i'm attempting to do and told me to email her when i felt as though i would be comfortable with changing my medication profile as right now i'm rather stable, albeit with moderate sexual dysfunction and some problems with insomnia. she told me to cautiously continue to taper the benzodiazepine at whatever pace i feel comfortable at as she figures out a way to try to remove pregabalin with minimal suffering and to not touch escitalopram nor hydroxyzine and i feel totally fine with that plan for now.

if switching ssris, i told her that at the end of may i am resigning from my career to enter a doctoral program in september and that might be the ideal time to attempt such a switch. the only caveat is that the exposure therapy of going to work daily might make it a bit more tricky to acclimate to the new drug as i'd be kinda just sitting around, so if that's the case, then i'd have to actively go out daily for extended periods of time because for me, exposure therapy is crucial in general, but especially when making medication changes.

not sure when my next appt is as she still has to set it up, or i have to call tomorrow to set it up myself, but i have constant access to her via email or her nurse's call line.

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3 hours ago, basuraeuropea said:

 she's quite understanding and is an advocate for what i'm attempting to do and told me to email her when i felt as though i would be comfortable with changing my medication profile as right now i'm rather stable, albeit with moderate sexual dysfunction and some problems with insomnia. she told me to cautiously continue to taper the benzodiazepine at whatever pace i feel comfortable at as she figures out a way to try to remove pregabalin with minimal suffering and to not touch escitalopram nor hydroxyzine and i feel totally fine with that plan for now.

Sounds like you have a really good pdoc........I'm glad you feel comfortable with the current plan...

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