JaCo: mirtazapine - which dose for reinstatement?

[JaCo]

Hi everyone- I’m new to the forum. I wondered what thoughts are about which dose of mirtazapine to reinstate at. I started mirt in June 2018 and went from 15mg to 30 to 45mg. Was at this dose until March 2021. Then tapered alternating 45 mg and 30 for a month, then 30 for month, then 30 and 15 mg then 15 mg for a month. WD probs started when alternated 15 and 0 mg- so after a week went to 7.5 mg for 3 months. Then tapered down over a couple of months to around 1.8mg. Was ok until alternating with that and 0mg. Doc said go CT, so did in May 2022. I had bad WD for 2 weeks but these improved a little. However, last 2 weeks situation seems to be worse  and feels like WD /relapse. Am not in a good place at all. I’ve contacted Docs about reinstating on mirtazapine but not sure which dose, esp. given I was doing ok on v low doses. I’ve read some v interesting info on SA , but wondered if anyone had thoughts on which dose would be best to start back on. I’ve read lower might be better. I’ve been CT for about 7 weeks. I appreciate no one can give medical advice, but haven’t found Docs to be esp. helpful at times. 
 

am happy to elaborate on my experiences thus far if that might help anyone.

 

JaCo

 

 

[JaCo]

Hi

i should clarify/ add that I didn’t taper down by 10% but by 50%. I also think, having read articles and comments on SA, that I ‘rushed’ the tapering at lower dose - I think I should have stayed at 3.75 mg for longer, then tapered by 10%. Although I felt ok at 1.8mg I think I went too quickly from 3.75 to 1.8 to CT. 
 

I don’t want to go back on mirtazapine or any other AD but this WD doesn’t seem to be working out. Anxiety is still not great and at times is ‘off the scale’. Depressive episodes are increasing and getting worse than initial I have no appetite. I can’t focus / concentrate. I can’t sit still for long esp in day.
 

However, am not sure about reinstating, having read info on SA about it. Am not sure if it will work / if I have left it too late, and if reinstating, what dose to go back at.  Doc, following my suggestion, agreed I should go back on 3.75mg, but I wondered if I should start on 1.8 mg. Or not reinstate and carry on? From SA articles/info it seems it’s better to reinstate - ‘be kind to yourself’ - and at a low dose, hope it works, stablelize, then have another go at tapering but by 10 % and slowly. 
 

on the other hand, some stories re : reinstating, even at low dose, indicate it may not work or make things worse?   And that nervous system will eventually heal if continue with CT.  So am still unsure about best option, and frightened by making ‘wrong’ decision.

 

am frightened to reinstate, but also that I’ve left it too late to reinstate. That reinstating won’t work or will make things worse, but that not reinstating will make things worse in the longer term - there’s no timeframe when things may get better if don’t reinstate or if at all. Feeling confused and exhausted and desperate

 

J
 

 

[JaCo]

Am starting to think I should give reinstatement a go and at 1.8 mg rather than 3.75mg. I know no one can make this decision for me , but if anyone could comment on if it makes good sense, that would be helpful.  
 

I’ve read SA articles and threads on reinstating but, like others, I could do with some well  informed support comments re: my situation and plan. Am getting more concerned that window of opportunity for effective reinstatement is closing/has closed

 

J
 

 

[JaCo]

Actually, I am probably nearer 10 weeks since CT.

j

[getofflex]

Hello, and welcome to SA.  We are a volunteer-run community of people who have been or are getting off of psychiatric drugs.  It sounds as if your nervous system is protesting because you tapered too fast.  However, another thing that will cause your nervous system trouble is alternating doses.  This causes an uneven level of the drug in the bloodstream from day to day, and tends to further destabilize the nervous system.  Many doctors don't realize this, and wrongly tell their patients to do this. I will discuss reinstatement at the bottom of this post, after giving you some basic information.  

 

Can you please give us more specific about your tapering?  If you don't remember the exact day, make a good guess, or say "early May" or "third week of May", etc.  This will help us advise you properly.  Thank you. 

 

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, and why it's so important to taper slowly and carefully, and be very cautious about changing our doses: 

 

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

 

 

The symptoms you describe sound like classic WD symptoms.  How is your sleep, and your eating and basic functioning?  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

 

Finally, going back on a small dose of your drug, or increasing your dose, which we call reinstatement, is best done very carefully.  This is temporary, and after stabilizing you would then taper gradually off of this.  There is some risk involved, but we will start at a very low dose to minimize this risk. If I were you, I would try a reinstatement dose of 0.5 mg mirtazapine.  If you do OK on this, and need more, we can carefully and gradually increase the dose.  Please give this at least a week, unless you feel significantly worse on the reinstatement.  Eventually, once you stabilize, you would then taper off of this.  

 

Here is some information about reinstatement.  

 

About Reinstating and Stabilizing to Reduce Withdrawal Symptoms

 

This link will tell you how to measure this very small dose.  You can make your own liquid, or order the liquid in the UK.  This link will explain how to do these things.

 

 Tips for Dosing Mirtazapine

 

I've given you quite a bit of information here.  Please read through it, and mull it over, and we will take it from there. In the meantime, take care of yourself, and take heart.  We in this forum have been through this, and we understand first hand the pain and discomfort you are going through.  Please know that the brain is amazing in it's healing abilities.  It takes time, but healing can and will happen. 

[JaCo]

Hi- thank you so much for all info and advice  I will read through it.   Re: my tapering, this is the best I can recall:

2021

ApriI started alternating 45mg & 30 mg. For that month.

May: 30mg for that month.

June: alternate 30  mg and 15 mg for a month.

July: 15mg for that month.

Up to this point everything had felt positive - felt brighter, lost some of weight, felt less ‘cut off’ /zombie like. 
August: alternated 15mg and 0mg for about 8 days. Had wd- insomnia, vertigo, severe panic attacks, couldn’t focus.

August 2021 - Feb 2022: 7.5mg everyday. Stabilised and felt fine. No more wd, could function, sleep.

2022

Feb: alternated 7.5mg & 3.75 mg for that month. 
March: 3.75mg everyday. Felt fine.

April: alternated 3.75 and 0mg for about 3 weeks. Felt fine, but didn’t sleep as well on 0mg evening. Then alternated 3.75mg and 2 days 0mg . Started with wd symptoms. Went to 1.8 mg everyday but still had wd. 
May: CT

initially no sleep. No appetite. Couldn’t concentrate/ focus. High anxiety - very wired. Had tremors/ shakes in night. But after 3, 4 weeks these improved . Could get off to sleep, woke up most nights but could get back to sleep. Appetite improved. Anxiety more manageable.
 

However, last 2 weeks these have become worse again. Some days and parts of day - usually evenings - are not as bad. but anxiety is less manageable, very little appetite, have indigestion every time I eat, I feel very low not just anxious. Can’t concentrate. Poor self image, and negative thoughts, emotions. Sleep getting worse. I’ve been awake all night tonight … v wired.

 

I have some diazepam- 2mg tablets. I haven’t taken any- what are thoughts on taking diazepam for short time whilst reinstating? 

 

thanks , again for all help. Let me know if you need more info.

 

 

 

[ChessieCat]

2 minutes ago, JaCo said:

I have some diazepam- 2mg tablets. I haven’t taken any- what are thoughts on taking diazepam for short time whilst reinstating? 

 

Q:  Have you taken any previously?  If yes, please add to your drug signature and include the usage, eg 2-3 times a week.

 

You can become dependent on them very quickly, as well they lose their effectiveness within a short period of time and then you end up having to stay on them even though they may not provide any relief or you end up taking more.  And of course they then need to be tapered as well.

 

The other reason for not taking a benzo is that it will make it difficult to see if reinstatement is working.

 

 

[JaCo]

Hi

Thanks for reply (and message). no I haven’t used before. 
 

if things don’t work out at 0.5mg , do I taper down from that?

J

 

 

[ChessieCat]

12 minutes ago, JaCo said:

no I haven’t used before. 

 

Thank you for answering my question.  If it was me I would definitely not be taking a benzo.

 

10 minutes ago, JaCo said:

if things don’t work out at 0.5mg , do I taper down from that?

 

If you reinstate 0.5mg, which is the amount that was suggested above by getofflex, and you feel obviously worse then you stop taking it.  You do need to try not to worry because that can add anxiety into the mix and because the symptoms can be similar it can be mistaken as an adverse effect when it is actually just plain anxiety.

 

If there is no change then you wait for at least 1 week and then reassess.  You might need to increase by another small amount.

 

If there is some improvement you wait for about 2 weeks and then reassess.

 

Please continue to let us know how you are.

[JaCo]

 

Ok - do I hold off from taking magnesium supplements whilst reinstating…. My anxiety seems to be getting worse- it’s definitely worse than last week… like a constant wave of anxiety I had when first went CT 

 

Thanks, again

j

 

[JaCo]

 

Hi

sorry about this - do I take meds in evening like I used to when reinstating?

Thanks

j

[ChessieCat]

8 minutes ago, JaCo said:

 

Ok - do I hold off from taking magnesium supplements whilst reinstating…. My anxiety seems to be getting worse- it’s definitely worse than last week… like a constant wave of anxiety I had when first went CT 

 

Thanks, again

j

 

 

If you were already taking magnesium it is okay to continue.

 

When making any changes it is best to only make one at a time.  When there is more than one variable, if something improvements or worsens it can be difficult to work out what caused it.

[ChessieCat]

4 minutes ago, JaCo said:

 

Hi

sorry about this - do I take meds in evening like I used to when reinstating?

Thanks

j

 

If you had no issues when taking mirtazapine at night before, then take it at the same time.  However, it is important to take it at about the same time every day.

[JaCo]

Ok. Thanks. I know this is my choice and no one can make it for me, but given your experience and insights from others, do you think this , reinstating, is better option than trying to ‘tough out’ WD?  From reading info, others accounts etc on SA, I realise there are possible pros and cons with both, but am thinking reinstatement is better option… that said I have anxiety about it

[ChessieCat]

Unfortunately nobody can say whether reinstatement will work.  When it comes to psychiatric drugs, we are all an experiment where N=1.  There are so many variables.  Some members try reinstatement soon after they stop their drug and it works, and for some it doesn't.  The same for members who reinstate after quite some time has passed, for some it works and other it doesn't.  There does not seem to be an particular reason for why it does/doesn't work.  That is why SA recommends only starting with a small dose.

 

If you are anxious about it then start with a smaller reinstatement dose.

 

Some of the anxiety that you are experiencing may be from withdrawal.  It generally takes about 4 days for a dose to get to full level in the blood and a bit longer for it to register in the brain which is why I gave the amount of time to wait in my above post.

[JaCo]

hi - in the very short term (e.g., for next week) whilst i see how reinstatement goes (i.e., if there are any effects) and thereafter until i can work out how to make own suspension or arrange compound chemist, am I ok to just pil cut (  I've looked on threads but feel a bit overfaced with all info on this atm)? 

 

I can cut 15mg pils in half to 7.5mg and again to 3.75 and again to 1.875mg quite readily.  Thereafter, it's a bit trickier but can roughly half again to 0.9375mg and then again to 0.46875mg - is this near enough to the 0.5mg recommended? 

 

Do i need to weigh the various 'pieces' - i've read that weight is not same as dose?

 

could I grind up tablet and divide accordingly into smaller doses, and weight these - then either put powder into glass of water and drink or swallow powder directly?

 

apologies for all questions

 

 

[getofflex]

Better options would be to grind the tablets into a powder and weigh this, or make a liquid.  The link I gave you above explains all about this.  

 

Tips for Dosing Mirtazapine

[JaCo]

hi -  thanks - I did read through but am frazzled and can't concentrate very well atm.  so for now if I grind up pil and weigh out 0.5mg, i can just take this amount (0.5mg) with any amount of water or just dissolve in mouth or put in gel cap (if necessary)?

 

thank you,

j

[marie123]

Hi JaCo. I think it would be a good idea to weigh the amount 0.50 mg Mirt because that is the way you were taking it before you stopped it. Right now your brain would like the sameness. Do you have a scale? You can always do liquid later once your stable if you want to. You stopped taking Mirt in May. Was it the end of May? Remember when you reinstate some of your symptoms will stay for a while but if you feel some improvements it's a good sign. You don't need to put it in a gelcap. Just drink down with water. That is what I do. Marie.

 

Edited July 15, 2022 by marie123
wrong amount

[JaCo]

Hi Marie- thanks so much for your reply. I’ve ordered some scales - should arrive tomorrow. Was just cutting before but it makes more sense to grind and weigh.
 

CT was early May - about 10 weeks ago.

 

thanks for advice - glad I don’t need to bother with gel caps … I assume I can take 0.5mg with any amount of water.

 

hope you are ok

j

[ChessieCat]

54 minutes ago, JaCo said:

I assume I can take 0.5mg with any amount of water.

 

Yes.

[JaCo]

Thank you! 

[marie123]

Hi JaCo. When I cut the pill to weigh it I just cut it into chunks and weigh a piece to get my weight. If I need a bit more weight I will put a smaller chunk with it on the scale. If I need less I use a metal nail file to trim it. Some people grind the pill down and use powder. The thinking is that it is more evenly distributed. I've never noticed a problem doing it my way. Whatever works for you. Marie.

[JaCo]

Ok. Thanks, again Marie

j

[JaCo]

Hi have just reread thread on reinstating and was wondering- since am 10 weeks CT would it be worth trying supplements for WD (eg. Magnesium)  first for a couple of weeks tosee if they help and if not, then try reinstating…

from reading threads - earlier is better , although I know it’s different for each person… just wondered if roughing out with supplements for a couple more weeks would make much difference if then decided to try reinstatement…

 

J

[getofflex]

The earlier you do a reinstatement, the more likely it is to work, so keep this in mind.  Like Chessie Cat said earlier, we cannot predict whether or not reinstatement will work for you.  That is why we suggest a very low reinstatement dose, to lower this risk.  It's testing the waters, so to speak. One thing you have in your favor, is that you have not been on a carousel of drugs like many others have.   This is a decision only you can make.  

[JaCo]

Thanks, again, getofflex - I appreciate your help.

I know it is my choice , am not expecting anyone to make it for me. I just don’t want to put mirt back in my system if it will make things even worse, or only help to manage WD symptoms at best -  if supplements, such as magnesium, may also help to manage WD symptoms.

 

Atm I have various WD but the worst is  anxiety and anxiety/ panic attacks - esp at night and wondered whether magnesium supplement might help. If so, I’d probably try to carry on. If not, I’d reinstate. I was thinking of trying supplements for a couple of weeks and if not having much effect after a week or so, try reinstating. 
 

I wondered what others (more informed than me) thought about this - whether it’s worth trying, or a bad idea. Whether 2 weeks is enough for supplement to have effect, whether delaying reinstating is worth it given overall effect of supplement.

 

I’ve read threads on SA and it seems magnesium doesn’t work for everyone but it is one of few supplements that SA recommends.
 

ChessieCat suggested it was ok to continue taking magnesium and reinstate if already taking but not to start taking magnesium and reinstate at same time - which I understand. This also made me wonder if it was worth trying magnesium before trying to reinstate.

j

 

 

 

[ChessieCat]

I think if magnesium was going to be of any help with the anxiety that you would know within a day or so.  It is better to take small amounts throughout the day instead of one or two larger doses. 

 

Magnesium

 

If you take calcium they need to be taken 2 hours apart, otherwise the calcium would cancel out the calming effect of the magnesium.

[JaCo]

Cheers ChessieCat.

j

[getofflex]

9 hours ago, JaCo said:

Atm I have various WD but the worst is  anxiety and anxiety/ panic attacks - esp at night and wondered whether magnesium supplement might help

Have you tried any non drug techniques to decrease and cope with the anxiety?  Anxiety tends to feed on itself, and cause a downward spiral.  There are ways to prevent this.  Here are some links. 

 

Audio:  How to Recover from Anxiety - Dr Claire Weekes

 

 

15 hours ago, ChessieCat said:

Audio:  First Aid for Panic (4 minutes) Female voice - getselfhelp.co.uk
 

Audio:  First Aid for Panic (4 minutes) Male voice - getselfhelp.co.uk

 

 

 

Emotional Spirals

 

Acknowledge Accept Float

 

Music to Calm Anxiety

 

Breathing Technique for Anxiety

 

Anxiety Stuff - all kinds of stuff about anxiety attacks and things that help ...

 

Meditation

 

CBT Course:  An Introductory Self-Help Course in Cognitive Behaviour Therapy

 

 

 

 

Edited July 17, 2022 by getofflex

[JaCo]

Thanks getofflex!

[JaCo]

Hi - re magnesium supplements and anxiety :

 are these to help reach RDI of 400mg, if that is difficult to - eg, if no appetite.

 

 If one can obtain 400mg of magnesium naturally  from food, is it necessary/ worthwhile taking the supplements? 
 

Or is the idea , re anxiety, to use supplements to go beyond the RDI, without taking too much over the RDI? Have read in SA that too much magnesium can cause stomach problems etc.

 

j
 

 

[getofflex]

I don't get that precise about it.  It's not to reach a recommended daily allowance, as much as it is to help us calm our nervous systems.  We take small amounts throughout the day.  Yes, too much mag can cause diarrhea.  Did you read the magnesium topic I linked above? 

 

Magnesium

[JaCo]

Hi - thanks for reply. I have read info on magnesium supplements - really useful. 
j

[JaCo]

Marie123- what scales do you use? I just got some and realise they don’t measure below 1mg😣  On another thread Gemini-20 scales are recommended, but a poster said these are  not reliable below 4mg… so I  am a bit confused (not for first time…) and wondered which you use…

j

 

 

 

[ChessieCat]

10 hours ago, JaCo said:

Marie123- what scales do you use? I just got some and realise they don’t measure below 1mg😣  On another thread Gemini-20 scales are recommended, but a poster said these are  not reliable below 4mg… so I  am a bit confused (not for first time…) and wondered which you use…

j

 

 

 

 

Brassmonkey used the Gemini 20 Scales for all of his taper except for the very last tiny doses which he weighed and then divided manually.

 

Look for posts made by him in this topic:

 

using-a-scale-to-weigh-and-measure-doses