Shooks: sertraline withdrawal after serotonin toxicity

[Shooks]

Hi all,

 

Brief overview. 6ft, 180pnds male from England. 

 

- Began Sertraline 9.21 after work-related stress brought me to my knees

- Titrated up to 150mg by 2.22 in conjunction with my mental health nurse

 

Around January of this year, I began to feel really, really unwell - diarrhea, muscle stiffness, tremors and roving-eye movements. The NHS in the UK is in a big crisis at the moment, and seeing anyone face-to-face is nigh on impossible. I was told it was just 'side effects, it will pass', then to increase dose/decrease dose etc. Later, tested for electrolyte disorder which was negative. Emergency ambulance called for me on 18th May after I thought I was genuinely dying. Finally, I was given a physical diagnostic assessment by two doctors who diagnosed moderate serotonin syndrome/toxicity. All in all, it had taken me 3 months to see somebody in person!

 

- Told to immediately cease SSRI 19th May. Given diazepam and cyproheptadine. Within 48hrs I felt so much better and this continued for 3-4 weeks. All SS disappeared

 

However, the brain zaps/sleeplessness/fatigue of withdrawal began around 5-6 days ago. I understand why I had to stop abruptly, but even so - 150mg to 0 overnight is a huge leap downwards.

 

It has been just over 4 and a half weeks since I last took my SSRI. Should I reinstate at a lower dose? The cyproheptadine is designed to clear out excess serotonin, so may have had an impact. Based on what I have read here, would 25mg be a good number to try to stabilise on?

 

Any help greatly appreciated!

 

P.S. this is such a wonderful resource. My cousin is a psych nurse and her knowledge pales in comparison.

 

P.P.S. Serotonin toxicity possibly caused by too high a dosage; more likely an interaction with an OTC sleeping tablet (diphenhydramine). No certain answer, however.

[getofflex]

Hello, and welcome to SA.  We are a volunteer-run community of people who have been or are getting off of psychiatric drugs.  I'm not surprised to hear you were diagnosed with serotonin syndrome.  150 mg is a pretty hefty dose of sertraline.  The starting dose for an adult is 50 mg.  Yes, it does sound like you are in withdrawal from cold turkeying the sertraline, because you were on too high a dose.  I will discuss reinstatement at the end of this post.

 

Can you please give us specific information in your signature about your drug history for all drugs you are on and have been on, especially for the past 18-24 months?  It would be especially helpful to have the details of your drugs in a concise vertical list (no symptoms), only drug names, specific dates (as best you can say for example early March if you don't recall the day) and dosages of each medication decrease or increase.  Use this format:

 

Drug name: date, dose, date, dose, date, dose…

Drug name: date, dose, date, dose, date, dose…

Etcetera

 

Please read the link below for instructions.  This will allow us to give you the best guidance.  

 

How to List Drug History in Signature

 

Here is some important information about how these drugs actually work.  This explains why we get symptoms from going off of these medications.

 

How Psychiatric Drugs Remodel Your Brain

 

 

This helps you understand what withdrawal syndrome is: 

 

Video on Recovery from Psych Drugs

 

Windows and Waves Pattern of Stabilization

 

 

Here is a link with checklists of common WD symptoms: 

 

Dr Joseph Glenmullen Withdrawal Symptom Checklists

 

 

Here are some techniques to cope with symptoms: 

 

Non Drug Ways to Cope with Withdrawal Symptoms

 

Stability is really important when we are tapering off psych meds.  Please read the link about stability:

 

Keep It Simple, Slow, and Stable

 

 

We don't suggest many supplements, but 2 that many of us find helpful are magnesium and omega-3 fish oil. Here are the links for info about those. It is suggested to add one at a time, and start with a low dose to see how it affects you. 

Magnesium

Omega 3 Fish Oil

 

I do believe you would be a good candidate for reinstatement, but first I need to see your drug history to determine a safe starting dose.   The sooner you start your reinstatement the better.  But, wait until we advise you, because if you do too high of a reinstatement, you run the risk of kindling your nervous system, which you don't want to do.  This is best done very carefully.  This is temporary, and after stabilizing you would then taper gradually off of this.  There is some risk involved.  Here is some information about reinstatement.  

 

About Reinstating and Stabilizing to Reduce Withdrawal Symptoms

 

I look forward to hearing back from you soon.

Edited June 14, 2022 by getofflex

[Shooks]

Thanks so much. It has nearly been a month, so I knew time was of the essence. My signature has been updated as best I can recall.

 

The generic advice on restarting SSRIs after serotonin toxicity is to 'start on a lower dose.' But what does that mean? I told my doctor that I was worried about withdrawals from abruptly stopping, but he seemed unfazed by it. And here we are...

 

My withdrawal symptoms seem to have to got worse last couple of days - very sore neck and shoulder muscles, and general feeling of being unwell. Puts my mind at rest that they are part of Dr. Glenmullen's checklist.

Edited June 14, 2022 by Shooks

[Kaervin]

On 6/12/2022 at 8:58 AM, Shooks said:

 

 

- Began Sertraline 9.21 after work-related stress brought me to my knees

- Titrated up to 150mg by 2.22 in conjunction with my mental health nurse

 

 

Welcome to SA,

 

I too tried out 150mgs but only for a few days and it made me unwell. That is what caused me to do my first med switch to escitalopram.

 

As Getofflex said, you are not too far out from your last dose so reinstatement and a slow taper may be beneficial. If you make the decision to go back on make sure you do it slowly. You might feel some initial relief, but it may take a few weeks to stabilise. Ideally you want to get on the lowest dose that will bring you back to functional. 

 

There are several people on this site dealing with sertraline withdrawal and tapering. Once you figure out your game plan we can all navigate through this mess together. 

 

Be sure to read the links provided to you by the moderator.

 

[Altostrata]

Welcome, @Shooks

 

I am sorry you experienced serotonin syndrome from excessive SSRI dosing. Missing that symptom pattern when you reported it was negligent on the part of your prescriber.

 

On 6/12/2022 at 5:58 AM, Shooks said:

Told to immediately cease SSRI 19th May. Given diazepam and cyproheptadine. Within 48hrs I felt so much better and this continued for 3-4 weeks. All SS disappeared

 

However, the brain zaps/sleeplessness/fatigue of withdrawal began around 5-6 days ago. I understand why I had to stop abruptly, but even so - 150mg to 0 overnight is a huge leap downwards.

 

How long did you take diazepam? When did you stop it and cyproheptadine? Please add the diazepam and cyproheptadine information to your signature.

 

Are you taking any other drugs? Have you ever taken any other antidepressant?

 

It important in this recovery period that you not drink alcohol. If you drink coffee, you may wish to gradually decrease caffeine, as you may have become sensitized and it now is affecting your sleep.

 

Not sure if SSRI reinstatement would be best for you. You may be sensitive to any serotonergic.

[Shooks]

I was given six days worth of diazepam - 2mg x 3. I took as and when needed. 

 

I was on cyproheptadine for four weeks. 8mg x 3 for the first four days, and then 4mg x 3 for the rest of the time. 

 

I had a few months on Sertraline back at the beginning of 2018 reaching 50mg, but tapered off it slowly and successfully. No other drugs. I will add this and all other informartion to my signature.

 

I have been booze-free and caffeine-free for nearly a year now! 

 

 

[Altostrata]

What was the last date you took diazepam or cyproheptadine? Was there a period when you were taking only cyproheptadine? How did it affect your symptom pattern?

[Shooks]

12 minutes ago, Altostrata said:

What was the last date you took diazepam or cyproheptadine? Was there a period when you were taking only cyproheptadine? How did it affect your symptom pattern?

 

I took the last of the Diazepam on Friday. I took diazepam 2 x 3 for the first three days after my SS diagnosis, and then only when I felt I really needed it after that.

 

There were lots of days when I took cyproheptadine alone. I credit it for getting rid of most of my SS symptoms - occular clonus (roving eyes), gait disturbance etc. All had cleared up by the beginning of June. I seemed to have a patch of feeling really good before withdrawal hit. I knew it was withdrawal as soon as the brain zaps started...

[Kaervin]

5 hours ago, Shooks said:

 

I took the last of the Diazepam on Friday. I took diazepam 2 x 3 for the first three days after my SS diagnosis, and then only when I felt I really needed it after that.

Alto is asking for your total usage of diazepam because that is another medication class that has severe withdrawals.  If your body is not dependent on diazepam you may be able to avoid withdrawals by stopping it as soon as possible.  Typically it takes just a couple of weeks of regular usage to incur physical dependency.

 

If you haven't used diazepam that long or often there may be no need to ween yourself off as going on a taper schedule may prolong your use of it and actually get your body dependent.

 

So you only took it regularly for 3 days and then as needed for a few more days after that? You may want to avoid taking any more then if you can manage it. As someone who went through withdrawal from benzodiazepines I can attest that it is an unpleasant experience.

[Altostrata]

I also ask because you may have seen the emergence of withdrawal symptoms after the diazepam wore off. It has a washout period of at least several weeks.

 

Given diazepam helped, I would request more diazepam for very minimal daily dosing (perhaps a quarter of a tablet) for several months. I know UK doctors don't like to prescribe benzos, but you had actual serotonin syndrome, which is a very serious adverse reaction, and you need more time to recover from it.

[Shooks]

21 hours ago, Altostrata said:

I also ask because you may have seen the emergence of withdrawal symptoms after the diazepam wore off. It has a washout period of at least several weeks.

 

Given diazepam helped, I would request more diazepam for very minimal daily dosing (perhaps a quarter of a tablet) for several months. I know UK doctors don't like to prescribe benzos, but you had actual serotonin syndrome, which is a very serious adverse reaction, and you need more time to recover from it.

 

Yes, I think you are absolutely spot on. One curious thing did happen about a week and a half or so after I stopped, however - I had a really bad allergic reaction to something. Even my face broke out in hives. I thought it might be a new detergent, but now I am not so sure...

 

I will do my best to get a benzo prescribed, even if it is just a week's worth that I can then split. 

 

Going forward, it will be a cold day in Hell before I go on medication again. But... I am realistic and know that one day I might not be as strong and may feel the pressure again to go onto something. Am I best avoiding SSRI/SNRI medication now due to sensitisation?

[Altostrata]

3 hours ago, Shooks said:

Am I best avoiding SSRI/SNRI medication now due to sensitisation?

 

That is my guess.

[Shooks]

20 hours ago, Altostrata said:

 

That is my guess.

 

Thank you so much for your support and advice. I am truly grateful.