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Side Effect Profile Generally Same for Each SSRI?


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so, i have my last appointment with my current psychiatrist tomorrow and i'm unsure whether she will want to make a last medication change or whether she will defer to the following psychiatrist. i have issues to discuss, however.

i am well aware that certain ssris are more effective than others at the individual level for various maladies, however, are the side effect profiles generally the same for each? specifically, i'm currently taking 10mg/day of escitalopram and the emotional truncation is terrible. i cannot cry and counterintuitively this is quite distressing. on the other end of the spectrum, i don't find joy in anything either. there is a significant amount of apathy and lack motivation with regard to everything. relatedly, i have no libido which is a side effect that has plagued me for quite some time. all of this sounds like dopaminergic dysregulation to my untrained ear, but who knows. i mean, it also reeks heavily of depression as well, but i don't think that's the most influential contributing factor here.

as i have decreased the ssri and increased lamotrigine, suicidal ideation has stopped completely, but everything else aforementioned has taken its place and that's not peachy. i have read anecdotally that lamotrigine can restrict affect, although at 150mg/day i'm not sure this medication is the culprit over the ssri; perhaps they are working in tandem. alternatively, it's possible these are symptoms of the illnesses themselves.

back to ssris, though, as it seems as though i'm stuck on one. if i were to try another, and really the only other that i think may be useful over escitalopram is fluvoxamine, is it likely that i will experience these same side effects?

in terms of immediate distress, anxiety and panic are still very much problematic as are intense racing thoughts, particularly when i'm highly anxious.

i'm on the fence on asking the psychiatrist tomorrow to increase lamotrigine further while decreasing escitalopram or whether to inquire on a switch from escitalopram to another ssri.

i'll see what she has to say, but anyone's insight here may help in facilitating that discussion.

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1 hour ago, basuraeuropea said:

so, i have my last appointment with my current psychiatrist tomorrow and i'm unsure whether she will want to make a last medication change or whether she will defer to the following psychiatrist. i have issues to discuss, however.

i am well aware that certain ssris are more effective than others at the individual level for various maladies, however, are the side effect profiles generally the same for each? specifically, i'm currently taking 10mg/day of escitalopram and the emotional truncation is terrible. i cannot cry and counterintuitively this is quite distressing. on the other end of the spectrum, i don't find joy in anything either. there is a significant amount of apathy and lack motivation with regard to everything. relatedly, i have no libido which is a side effect that has plagued me for quite some time. all of this sounds like dopaminergic dysregulation to my untrained ear, but who knows. i mean, it also reeks heavily of depression as well, but i don't think that's the most influential contributing factor here.

as i have decreased the ssri and increased lamotrigine, suicidal ideation has stopped completely, but everything else aforementioned has taken its place and that's not peachy. i have read anecdotally that lamotrigine can restrict affect, although at 150mg/day i'm not sure this medication is the culprit over the ssri; perhaps they are working in tandem. alternatively, it's possible these are symptoms of the illnesses themselves.

back to ssris, though, as it seems as though i'm stuck on one. if i were to try another, and really the only other that i think may be useful over escitalopram is fluvoxamine, is it likely that i will experience these same side effects?

in terms of immediate distress, anxiety and panic are still very much problematic as are intense racing thoughts, particularly when i'm highly anxious.

i'm on the fence on asking the psychiatrist tomorrow to increase lamotrigine further while decreasing escitalopram or whether to inquire on a switch from escitalopram to another ssri.

i'll see what she has to say, but anyone's insight here may help in facilitating that discussion.

what about just increasing the lamictal? I know you dont want to be on more meds, but when things arise that have mysterious origin only changing one thing at a time may help narrow it down. If things get better than maybe the lamictal will hold you and the ssri isnt as important. If the affect situation gets worse, than you know that its at least partially the lamictal and you may have to put a ceiling on how high that dose goes. It seems like switching an ssri introduces a lot a risk for what may not be a great benefit. 1) if you're transitioning pdocs, it may not be the best time to introduce a potentially tricky med change, 2) while there is some variation in SSRIs, I dont know that the fluvoxamine would be any better for emotional blunting. In fact it can be sedating so it might actually be worse, 3) cross titrating up on lamictal while down on one ssri but also haveing to go up on another ssri seems like a lot of pharmaceutical cooks in the kitchen, especially if you are having panic symptoms 

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45 minutes ago, Iceberg said:

what about just increasing the lamictal? I know you dont want to be on more meds, but when things arise that have mysterious origin only changing one thing at a time may help narrow it down. If things get better than maybe the lamictal will hold you and the ssri isnt as important. If the affect situation gets worse, than you know that its at least partially the lamictal and you may have to put a ceiling on how high that dose goes. It seems like switching an ssri introduces a lot a risk for what may not be a great benefit. 1) if you're transitioning pdocs, it may not be the best time to introduce a potentially tricky med change, 2) while there is some variation in SSRIs, I dont know that the fluvoxamine would be any better for emotional blunting. In fact it can be sedating so it might actually be worse, 3) cross titrating up on lamictal while down on one ssri but also haveing to go up on another ssri seems like a lot of pharmaceutical cooks in the kitchen, especially if you are having panic symptoms 

thanks for your response, @Iceberg. so, it had crossed my mind that increasing just lamictal would be one of her suggestions, but i don't think that's going to solve my problems. like, i increased from 100mg/day to 150mg/day with these exact complaints and here i am in the same position i was in at 100mg/day. so i strongly think the apathy/affect blunting/lack of libido/lack of motivation are at the very least partially caused by the ssri.

i agree that increasing lamictal while cross-tapering from one ssri to another is not at all what i'm going to propose nor what i would agree to. it'd be too much to handle at present. what i don't really feel comfortable doing either, however, is increasing lamictal only to reduce lexapro a month or so later because i become particularly accustomed to the anxiety relief that any new medication that is effective provides and then have a really tough time changing anything else, e.g., reducing an ssri, without something compensatory.

the lexapro-to-luvox switch is only appealing in that i may be able to get by on a non-equivalent lower dosage of luvox which may minimize the side effect burden. it's sedative properties are exactly why it *might* work at a dosage lower than the equivalent dosage of lexapro i'm taking now. i don't know if that would prove to be true, though.

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2 hours ago, basuraeuropea said:

well, my doctor called in sick today which is unfortunate. they rescheduled for next friday, the 23rd.

i was very much looking forward to speaking with her today because i'm well enough but not well, if that makes sense.

Can’t remember-have you tried Luvox before? 

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1 hour ago, Iceberg said:

Can’t remember-have you tried Luvox before? 

i have. i have only been on 300mg/day. at that dosage it had the same side effects as the other ssris/snris.

i was taking it alongside an atypical (as well as clonazepam and lyrica). i don't really remember what it was or wasn't doing because the whole antipsychotic treatment phase is a terrible blur. looking back, i cannot understand why my treating psychiatrist didn't pull me from the class rather than having me try some five different aaps when i was clearly very much worse off. to be fair, i can't believe that i didn't demand to be pulled from the class then either.

anyhow, because it's difficult to tease what is doing what when there are other medications involved, it's risky to replace lexapro with luvox and even more risky to try to cross-taper to an non-equivalent lower luvox dosage.

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1 hour ago, CrazyRedhead said:

If I remember correctly, 300mg/day is the max recommended dose of fluvoxamine.

it is and at that dosage i wouldn't expect it to have milder side effect profile than any of the other ssris. because i'm on 10mg/day of escitalopram, i wouldn't cross-taper to 300mg/day of fluvoxamine.

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i haven't yet had my appointment which was rescheduled for this friday, although my psychiatrist had her nurse call and instruct me to increase lamotrigine from 150mg/day to 175mg/day and remain there for two weeks after which i'm to increase again to 200mg/day. she said that on friday she will have further instructions or suggestions on what to do with escitalopram.

i really don't understand the ultra slow lamotrigine titration schedule that she has had me follow. from what i've gathered this isn't the norm at all, and i'm struggling to find an reasonable rationale. the entire titration process has been done in 25mg increments followed by cursory two week 'adjustment' periods. it's quite frustrating as it's taken months and others do this more quickly.

she also suggested that i take a portion in the evening with the rest in the morning. she suggested the majority in the evening with a small amount in the morning, although that's not going to work for me, so i don't know if taking it all in the morning is best or if taking a small amount in the evening is best. she also stated that lamotrigine can affect iron and folate absorption, so she recommended iron and folate supplementation. i have read, however, that folate supplementation can interfere with lamotrigine's efficacy, so i'm wary of taking it without discussing further.

@Iceberg, may i ask how much lamictal you are taking daily?

Edited by basuraeuropea
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6 hours ago, basuraeuropea said:

really don't understand the ultra slow lamotrigine titration schedule that she has had me follow. from what i've gathered this isn't the norm at all, and i'm struggling to find an reasonable rationale. the entire titration process has been done in 25mg increments followed by cursory two week

My one thought- it’s possible she’s trying to ease you in to any possible activation that might come and make your anxiety worse 

I take 200 twice a day. It is purely for long term stability promotion. Never helped for anything acute, but might have been helpful in lowering the lithium that I wasn’t tolerating well 

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2 hours ago, Iceberg said:

My one thought- it’s possible she’s trying to ease you in to any possible activation that might come and make your anxiety worse.

this is a great theory; something that i had not considered but is understandable given that i had such a difficult time getting to 100mg with major increases in anxiety, ocd and depression.

2 hours ago, Iceberg said:

I take 200 twice a day. It is purely for long term stability promotion. Never helped for anything acute, but might have been helpful in lowering the lithium that I wasn’t tolerating well 

i know that you are taking a number of other medications (as most of us are here), and it's quite difficult to tear apart what is doing what, but does lamictal have a mild side effect profile for you? i hope to get rid of the ssri, but i don't know how realistic of a goal that is. i'm not sure of the dose dependency of lamictal's side effect profile, but hopefully it's not exponential. currently they are pretty mild with the most notable being extremely vivid dreams, some mild acne, and a bit of memory/cognitive impairment that's embarrassingly produced less than eloquent expression of thought. i noticed all of these right away and they all haven't really worsened with the exception of perhaps the cognitive impairment, albeit only slightly.

i'm glad that it's working well as long-term mood stabilizer. hopefully it'll work well for me long-term as well. i decided to continue to take the entire amount in the morning.

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7 minutes ago, basuraeuropea said:

this is a great theory; something that i had not considered but is understandable given that i had such a difficult time getting to 100mg with major increases in anxiety, ocd and depression.

i know that you are taking a number of other medications (as most of us are here), and it's quite difficult to tear apart what is doing what, but does lamictal have a mild side effect profile for you? i hope to get rid of the ssri, but i don't know how realistic of a goal that is. i'm not sure of the dose dependency of lamictal's side effect profile, but hopefully it's not exponential. currently they are pretty mild with the most notable being extremely vivid dreams, some mild acne, and a bit of memory/cognitive impairment that's embarrassingly produced less than eloquent expression of thought. i noticed all of these right away and they all haven't really worsened with the exception of perhaps the cognitive impairment, albeit only slightly.

i'm glad that it's working well as long-term mood stabilizer. hopefully it'll work well for me long-term as well. i decided to continue to take the entire amount in the morning.

I think, but am not sure, that the PI only requires splitting the dose above 200, although you may get better coverage. 
 

on its own, lamictal doesn’t really give me any issues. I do slur words at certain points of the day if I don’t time adderall right, but that’s mostly clozaril  dependant. However, I typically have a very high med tolerance. With the exception of clozaril and geodon I’ve been on the max dose of basically every med I’ve ever taken 

 

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9 hours ago, basuraeuropea said:

this is a great theory; something that i had not considered but is understandable given that i had such a difficult time getting to 100mg with major increases in anxiety, ocd and depression.

i know that you are taking a number of other medications (as most of us are here), and it's quite difficult to tear apart what is doing what, but does lamictal have a mild side effect profile for you? i hope to get rid of the ssri, but i don't know how realistic of a goal that is. i'm not sure of the dose dependency of lamictal's side effect profile, but hopefully it's not exponential. currently they are pretty mild with the most notable being extremely vivid dreams, some mild acne, and a bit of memory/cognitive impairment that's embarrassingly produced less than eloquent expression of thought. i noticed all of these right away and they all haven't really worsened with the exception of perhaps the cognitive impairment, albeit only slightly.

i'm glad that it's working well as long-term mood stabilizer. hopefully it'll work well for me long-term as well. i decided to continue to take the entire amount in the morning.

@basuraeuropea Have you given SNRI's a fair trial? Effexor works as an SSRI up until 150mg, then it begins to work on norephinephrine which supposedly gives a boost of energy & cognition for lethargic depression (less of the typical anhedonia effect). Brintillex acts as an SSRI but supposedly with less side effects.

I've been on Lamictal for a long time. It won't pull you out of a depression, but it supports longer periods of stability over time. I personally had side effects (with no noticeable benefit) above 200mg (cognitive/ memory impairment, skin sensitivity/ itching, lack of coordination) I think I read somewhere that for the majority of people (of course there are always outliers), it's not any more beneficial (for mood) above 200mg.

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hey @Blahblah. thank you for your suggestions, experiences and advice!

i haven't trialed effexor, but i've been on cymbalta. cymbalta worked well enough for anxiety, but didn't touch depression. none of the ssris + cymbalta have worked well for depression. trintellix/brintellix didn't work out for me as it was too activating and exacerbated the anxiety disorders. remeron did work well enough, but the impact it had on liver functioning and the weight gain were too much.

lamictal actually has pulled me out of a suicidal depressive state. i mean there are clearly signs of depression still present, but i'm feeling better than i was prior to introducing lamictal.

i bumped up to 175mg today and a new side effect popped up: dizziness. i hadn't experienced this during the titration period at all until now but it was severe enough several hours after taking the dose to have me pause and try to reorient myself and gain composure. even now, some eight hours after taking 175mg i'm definitely not able to walk around my apartment without become dizzy and unsteady on my feet. it seems rather severe for just a 25mg increase as i have to follow the wall to make sure that i don't fall. i'm not at all dizzy sitting here, it's when i move my head that the whole world swirls.

i realize that lamictal isn't likely to be effective over 200mg/day for the majority of people, but the goal here is to reduce the ssri's side effect burden, so there may be some benefit in raising the dosage higher than 200mg/day to control the anxiety disorders specifically. for instance, i decreased relatively easily from 20 to 15mg/day of lexapro once i reached 100mg/day of lamictal, but had major problems re: panic disorder reducing from 15 to 10mg/day of lexapro after having reached 150mg/day of lamictal. with more specificity, today, however, panic/anxiety is down some and this may be due to the slightly sedating effect of the medication (?). perhaps the dizziness/clumsiness is contributing to the reduction in anxiety because i'm just not as hyperaroused.

if i'm able to reduce lexapro another 5mg to wind up on only 5mg/day while increasing lamictal to 200mg/day then that would be fantastic, but i kinda think that a higher amount will be necessary given the difficulties i had stated in the paragraph above. this is all under the assumption that the dizziness subsides and i very much hope it does.

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I'll be honest: I skimmed the part about the specifics of your lamotrigine taper, but I will say that, generally speaking, the taper for that medication in particular is so slow because they want to decrease the likelihood of SJS/TENS. Both are incredibly rare, but you can increase the likelihood of it occurring if start doing things like missing doses, not taking the medication at the same time every day, increasing or decreasing the dosage too rapidly, etc. And then I don't know about your prescriber and their training, but I think that plays a role in what your taper might look like, for better or worse.

"Identifying the incidence of rash, Stevens-Johnson syndrome and toxic epidermal necrolysis in patients taking lamotrigine: a systematic review of 122 randomized controlled trials" —https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5312199/

As far SSRI, I'm probably not the best person to speak on this. I've only ever tried three. But I can tell you generally that SSRI medications, while similar in both effect and side-effect, they are not the same. And then I'd leave you with what my psychiatrist told me at one point. I didn't get it at the time because I was kinda like you in the "optimization" phase of trying to get the best medications, the least amount of side effects and greatest improvement. Do you wanna upset the apple cart? Because if you try another SSRI, there's a very real possibility it could do exactly the same, be better in some ways and worse than others or just generally worse. And then at that point, you'd then have to ask yourself, "Do I now stay on this medication, go back to the old one in the hope that it at least works the same and hasn't lost any efficacy or do I try yet another one?"

I don't say it to be pessimistic or ride the fence in terms of offering advice. I just think it's a very personal decision and all about calculating things like risk, stability, etc. And no one can make that decision for you. And I finally got what my psychiatrist was trying to say. I don't upset the apple cart as much these days. That's not to say I've given up on meds or my particular cocktail. I do. But I try to do it smarter and also add in other things like therapy, exercise, etc. to create greater improvement without risking losing other things or upsetting everything entirely.

And don't get me wrong. I still do my research, both in the name of helping myself and because I'm a psychopharm nerd — like I'm really curious about the new antidepressant they're just about to come out with or already have: Auvelity or dextromethorphan-bupropion. If money weren't an issue and I could afford it while still on patent, I'd at the very least talk to my doctor about it. I don't know if I'd jump on it immediately, assuming I had his blessing, but it'd be tempting. Thank God I don't have money though, so it's not even an issue. Haha.

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2 hours ago, psychwardjesus said:

Do you wanna upset the apple cart? Because if you try another SSRI, there's a very real possibility it could do exactly the same, be better in some ways and worse than others or just generally worse.

at this point, yes, i am very much willing to upset the apple cart by slowly chipping away at the ssri. i was once on 25mg/day of lexapro and i'm now on 10mg/day and not any less unstable with regard to the anxiety disorders and in a far better position with regard to depression. lamictal has been a great replacement thus far, although i do have reservations regarding how much more lexapro can be removed safely while titrating lamictal to compensate. i'm particularly concerned regarding a relapse into the hellish world of unending panic, although the very slow decrease of lexapro in conjunction with the very slow increase in lamictal has me slightly more at ease with this not happening too severely nor too abruptly and without means of remediation. i also have hydroxyzine to take as needed in an emergency which may help in the short term, but can't take the place of a core medication as it's too weak.

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