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Cycling through SSRIs


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I've been through citalopram, mirtazipine (all the way up to maximum dose), and fluoxitine (was 40mg, now back down to 20mg and coming off). Next, my doctor insists on Sertraline. To be honest, though, I've been on SSRIs for 8 months and none of them have worked. All of them have made me worse in some way. However, my doctor refuses to use any other antidepressants, or consider other routes.

I'm wondering if anyone could give me any ideas on what to suggest to him?

Thanks,

N

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I've been through citalopram, mirtazipine (all the way up to maximum dose), and fluoxitine (was 40mg, now back down to 20mg and coming off).

Just curious why your doc is giving up on fluoxetine at 40 mg. My pdoc told me that the effective doses for most of her patients tend to be 20 mg for depression, 60 mg for anxiety, and 80 or 100 mg for OCD. I have all three of these (lucky lucky girl). I stopped feeling suicidal after being on 10 and 20 mg for several weeks, but I still didn't feel "right". 40 mg actually made me feel worse--lots of anxiety. Going up to 60 mg helped a lot, and going up to 80 helped even more. It took me a few months of steadily increasing doses to feel stable, but it did work for me. (And I'd been through three other SSRIs before, none of which helped). So, while there's something to be said for trying other drugs, it's also important to make sure that you try the right dose (or, rather, your pdoc has you try the right dose) before giving up on an SSRI. In hindsight, now I realize that at least two of the SSRIs I was prescribed before were at too low a dose; they never really had a chance to help me. If I'd had just one doctor back then that cared about monitoring me, I probably would have been healthy several years earlier.

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You have a lot of SSRI's left to try until you have no more options in that class. Finding the right one for you is trial and error - and mostly error - until you find the one that works for you. It takes a long time - given that each trial period should be at least 4-6 weeks, you should expect it to take several months.

Celexa

Remeron

Prozac

Zoloft

Lexapro

Paxil

...more

Wellbutrin is not an SSRI - it's an atypical antidepressant - but it's a popular choice by itself or in combination with an SSRI.

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SSRIs are all pretty much the same, but not all the meds you mention are SSRIs.

That said, when trying an SSRI (or any other med) the wisest way to go about it is to keep increasing the dose until either the side effects become intolerable or it starts working, whichever happens first. Not everyone responds to lower doses. The thing about fluoxitine is that it can take over six weeks to feel the full effects of each dose increase. If your pdoc has the feeling that you might benefit from a high dose SSRI, it's not the best one to try for that because it can take the better part of a year to get up to the max dose if you only increase by 20 mgs a month.

Fluoxitine is the only pure SSRI that you've tried btw. Giving zoloft a shot and taking it up to 200mgs before calling it quits isn't the worst of ideas.

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Before continuing with cycling through more SSRIs, consider

1. The day your physician/psychiatrist stops writing you prescriptions is the day he loses a patient and the money you bring. Question his/her credibility. Challenge the doctor to a plan that will wean you off these drugs altogether or, if she refuses, find a doctor who will do this with you.

2. Research has shown that a program of vigorous exercise is as effective in dealing with depression as SSRIs. The side effects of this treatment are all positive.

3. Research has shown that a 10 meeting series of cognitive behavioral therapy is as effective in dealing with depression as SSRIs. The side effect of this treatment is self knowledge and disciplined thinking.

4. Why would anyone who is remotely interested in your well being propose that you expose yourself to psychotropic medications with a wide range of negative side effects until you have seriously worked at #2 & #3 above? Why would you believe they have your best interests at heart?

5. If you, never mind others, if YOU value your life you must do your homework. You, after all, are the only person who has ultimate responsibility for your health. I suggest that you read, Joanna Moncrieff, The Myth of the Chemical Cure: A Critique of Psychiatric Drug Treatment, or Irving Krisch, The Emperor's New Drugs: Exploding the Antidepressant Myth or Robert Whitaker, Anatomy of an Epidemic. Any of these books could quite possibly save your life.

6. "Claims in drug monographs and advertising that selective serotonin reuptake inhibitor (SSRI) antidepressants work by normalizing serotonin levels are not based on scientific evidence and should be prohibited, says a leading US psychiatrist." The FDA admits this key evidence is lacking. See, http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1402373/

7. SSRInhibitors and SSREnhancers work equally well in a clinical setting in diminishing the symptoms of depression. How can this be possible if what pharma has been selling is based on fact?

8. It is a virtual certainty that you have become psychologically invested in these drugs, given your long experience with them. It will take courage to wean yourself, carefully and with supervision, away from these harmful substances.

9. Everyone admits that the placebo effect is hugely important in the evaluation of antidepressant drugs. But nobody wants to admit that the improvement in their symptoms is due to this effect. "Others, yes, but not me." This is silly on its face. Hence, do not accept personal testimonials that these drugs "work". Of course they do, as enhanced placebos with devastating,sometimes life-long side effects and that are very difficult and dangerous from which to withdraw.

I wish you good luck.

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ahab,

In case you haven't already noticed, this is a med-friendly site. Antidepressants have helped many, many people no matter what you consider to be their mechanism of action. FACT: take away ADs and you take away hope for a lot of people.

This is not to say that therapy doesn't help people. FACT: research has shown that the best course of treatment for someone with depression is antidepressant + therapy. FACT: Exercise is indeed helpful for depression, but exercise doesn't exclude other methods of treatment.

FACT: All drugs have side effects. Does this mean someone shouldn't take chemotherapy for cancer because chemotherapy has horrific side effects?

To be honest, your whole post is just parroting the anti-psychiatry rhetoric that we've seen many times before. If you don't like ADs then don't take them. But don't attack those who do.

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Thanks everyone for the help!

1. My doc told me that Mirtazipine was an SSRI... shows how much he knows (not much more than me).

2. @ ahab: I've done a lot of research. I've also been doing regular excercise for the last decade, CBT/any kind of therapy is not being effective for me at the moment (I'm in between therapists anyway), and I have never been weaned off any of the meds, I was told to just stop taking them by my doctor, which I did with no trouble (except for not sleeping for a week after I lost the sedative effect of mirtazipine).

3. @Velvet Elvis: I took each dosage of fluoxitine for well over a month before changing. - On a side note @StormBeforeCalm: I was the one who asked to raise my dose, which the doctor agreed with. When I said I didn't think it was working, we weighed up the side effects (which have lasted over four months without going away) versus the benefit that I could have on a higher dosage, and he felt it was best to first see if the side effects went away after long-term use if I went down to a lower dosage, before risking trying me on a even higher dosage. (Also, I have the feeling he doesn't care. It's not like I'm paying him.)

Lastly, my doctor refuses to combine mirtazipine with another AD, despite there being a clear benefit in me taking it for the sedative effect alone.

OH, and when I asked about treatment for OCD, my doctor made a flippant remark: "Oh, the antidepressants you're on should treat that". It's clear that they aren't. Thanks for the tip SBC, that I'd probably need a higher dose to treat that.

Thanks,

N

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SSRIs are all pretty much the same, but not all the meds you mention are SSRIs.

That said, when trying an SSRI (or any other med) the wisest way to go about it is to keep increasing the dose until either the side effects become intolerable or it starts working, whichever happens first. Not everyone responds to lower doses. The thing about fluoxitine is that it can take over six weeks to feel the full effects of each dose increase. If your pdoc has the feeling that you might benefit from a high dose SSRI, it's not the best one to try for that because it can take the better part of a year to get up to the max dose if you only increase by 20 mgs a month.

Fluoxitine is the only pure SSRI that you've tried btw. Giving zoloft a shot and taking it up to 200mgs before calling it quits isn't the worst of ideas.

Celexa is just a straight up SSRI, no?

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SSRIs are all pretty much the same, but not all the meds you mention are SSRIs.

That said, when trying an SSRI (or any other med) the wisest way to go about it is to keep increasing the dose until either the side effects become intolerable or it starts working, whichever happens first. Not everyone responds to lower doses. The thing about fluoxitine is that it can take over six weeks to feel the full effects of each dose increase. If your pdoc has the feeling that you might benefit from a high dose SSRI, it's not the best one to try for that because it can take the better part of a year to get up to the max dose if you only increase by 20 mgs a month.

Fluoxitine is the only pure SSRI that you've tried btw. Giving zoloft a shot and taking it up to 200mgs before calling it quits isn't the worst of ideas.

Celexa is just a straight up SSRI, no?

Yes, I missed that one in reading his post.

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Lastly, my doctor refuses to combine mirtazipine with another AD, despite there being a clear benefit in me taking it for the sedative effect alone.

Heh, throw him a curve ball by mentioning that venlafaxine (Effexor) plus mirtazapine (Remeron) is known as "California Rocket Fuel."

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IDK. Maybe get a second opinion at this point if your doc is being dismissive of OCD. OCD requires a slightly different approach to meds than straight up depression.

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@Kodos: Oh, he'd love that.

@rowen: I was thinking of asking him for seroquel, because it's known to be effective against nearly all of my problems. But he's not really open to med changes outside of SSRIs, so instead I've written a list of all of my weird and wonderful OCD problems that he can read so he understands the severity, and then we can discuss where to go from there.

Also trying to get him to refer me to a specialist for a second opinion, thus far no success.

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That sucks, hope you'll be able to convince him, not just for a second opinion but for all your treatment from now on. He sure doesn't sound too knowledgeable about MI stuff. If not, is there any way you can see a different GP to get a referral? That's how people often get around uncooperative GPs here. (I was lucky: my GP took about five minutes of talking to me to decide that she wasn't touching this with a ten-foot-pole and sent me onward. :P) I'm not sure how the UK system works (you're in the UK, right?), but considering that MI is often chronic, it would certainly be worthwhile to find a good doc to partner with.

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I want to relate something that has happened to me (in the US). Last year I moved back after being gone for quite some time. I no longer had a pdoc here. I went to see a GP because I needed to get my psych prescriptions filled. My GP refused to work with me. To make matters worse, my GP refused or was unable to give me a referral to a pdoc. I called around and all pdocs had about a 3 month wait for new patients. I was suffering from depression really badly, and I begged that GP to help me, and she would only give me Wellbutrin. Finally, on my own, I found a pdoc that would take me on short notice. Now I know why he could see me on short notice - he is a really crappy pdoc. But I will never forget how callous that GP was when I was desperate.

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Glad to know I'm not the only one with doctor-related trouble!

This is actually the second doctor I'm seeing for this. He was recommended to me by a friend of a friend who has BPD, and she said he was really good - was openminded, and didn't mind prescribing things that are expensive on the NHS/unusual/off-label. Compared to the first doctor, he is. But the more indepth we get into my problems, and the more complex things get, the more I'm finding that I'm hitting barriers.

Thing is, I don't want to switch GPs right now. I'm at uni, which only gives me a certain amount I'm allowed to be registered with - two surgeries, and he's the best doctor out of both of them. Also, he knows about everything, and I've already had to go through the trouble of explaining my situation to a new doctor once. I'd rather stick with him and be fussy further down the line. Hopefully, if I agree to go private, I ought to get a referral "soon".

Also, jt07, thanks for sharing your story. That must have been awful!

Thanks everyone for the advice,

N

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