jackp: struggling with Mirtazapine withdrawal

[jackp]

Hi All, 

 

I am struggling quite a bit with Mirtazapine withdrawal and would greatly appreciate any advice on next steps. My situation is somewhat unique as I also have circadian rhythm issues which I manage with Melatonin & a strict sleep schedule. I believe the interaction with these circadian issues and my withdrawal is compounding my issues which I will explain later in the post. For some background though, I have been on Mirtazapine 45mg for 1.5 years for anxiety & a bout of insomnia. I attempted to taper off the drug last year whereby I dropped from 45mg to 0mg over the course of about 4.5 months. Unfortunately this attempt failed once I hit 0mg as I started experiencing intense withdrawal symptoms which were not showing signs of improvement 5 weeks in. This only occurred on the final taper from 3.75mg to 0mg, I did experience withdrawal symptoms on prior tapers but these were manageable. I reinstated at a dose of 5.5mg - which I understand is higher than necessary but at the time I did not have this knowledge. Within the first night of taking 5.5mg, my withdrawal symptoms markedly improved and by the second night I was 100% back to normal. 

 

My plan following this attempt was to taper off the 5.5mg much slower. However, during my Christmas holidays from work, I generally give myself a break from melatonin and my strict sleep schedule and let my body sleep when it wants for a while. I have done this previously when I was on 45mg Mirtazapine and faced no issues. However, in the most recent Christmas break (Dec 2022) I started experiencing issues whereby changing the timing of the Mirtazapine was causing my sleep to become quite erratic and I also started having quite short sleep duration. I know Mirtazapine acts differently in lower doses and can be more sedating, but I was not expecting such severe impacts so I was quite confused. My doctor also did not know what was going on and the advice I was given was to stop Mirtazapine completely, which I did. As expected, I started experiencing the withdrawal insomnia again. It was at its worst at day 7 after discontinuing but surprisingly by day 10 it started to improve slightly. At this time I was still on holidays from work so I was allowing my body to sleep whenever it wanted. However, I am now 3 weeks post discontinuation and will have to return to work so I have resumed taking melatonin and trying to stick to a sleep schedule 3 days ago. Unfortunately, doing this has caused my sleep to return back to day 7 levels. 

 

My gut feeling is that the melatonin is causing these withdrawal issues to become worse. I have experienced similar issues in the past when I take melatonin but do not keep a strict schedule. This is sort of the case now as due to the withdrawal effects, I am waking up in the middle of the night at random times and am unable to return to sleep. This is quite distressing for me as melatonin is very beneficial in managing my circadian issues which is also necessary for proper sleep but it seems I may not be able to continue taking it. It also makes me wonder if the reason I did not experience any improvements in insomnia during the first time I withdrew Mirtazapine is because I had continued taking Melatonin. At the time I did not recognise this could be the cause. 

 

As I see, it I have 3 options now, all of which I do have some concerns with:

1. Reinstate Mirtazapine. This did work during my first withdrawal attempt so perhaps will work again. I could try and reinstate at a lower dose this time e.g. 1.8mg or alternatively for the first night I can take a higher dose e.g. 4.5mg to verify that this will work (the 5.5mg dose showed instant improvement within the first night during my first withdrawal attempt) and then subsequently lower the dose. My concerns with this are: 
   • My current situation is a bit different to my first withdrawal attempt as I have not had a consistent sleep schedule for the past few weeks. This makes it difficult to know when to time the Mirtazapine and given changes Mirtazapine timing was causing me issues during my Christmas break, I am afraid this will happen again. I guess if this does happen I can always stop the Mirtazapine, but I am afraid this will perpetuate my symptoms and also invalidate reinstatement as a future option. 
   • I am afraid if my dose is too low or something is off with the Mirtazapine timing, that I may only receive partial resolution of withdrawal symptoms but at the cost of my body once again becoming reliant on Mirtazapine. This would undo all the progress I have currently made in withdrawing and extend the duration of my withdrawal symptoms.
   • I am still a bit confused as to why my withdrawal symptoms only became so severe after dropping from 3.75mg to 0mg, but not during any of my tapers from 45mg to 3.75mg. Given this is not clear and I do not know what will happen as I slowly taper off again at these lower doses, I am a bit hesitant to get back on the drug. 
2. Stop Melatonin and attempt to stick to a sleep schedule without it. I have been able to do this in the past but I get around 1.5-2 hours less sleep per night which might be difficult considering I am already sleep deprived. I am also concerned it may be more difficult to stick to a schedule in general as my sleep seems to be different in this withdrawal period. 
3. Continue with just Melatonin for a few more days to observe changes. I am afraid of missing my reinstatement window if I do this.

 

I would really appreciate any advice on what option would be my best choice, or if there are other options I may have missed. I have to return to work tomorrow and I am unsure whether I will be able to function adequately. I am also quite anxious around having permanently lost my ability to sleep properly or permanently lost my ability to use melatonin to manage my circadian rhythm which would be devastating. I am hoping these are just irrational thoughts and that my sleep will return to how it was before Mirtazapine, but at the moment it feels like I will never be able to get off this drug. 

 

Thanks in advance for your time and any input you may have! 

[Gridley]

Welcome to SA, jackp.

 

It's obvious you're extremely well-informed on your situation and the drugs and supplements involved.  The circadian and melatonin issues are beyond our purview, but perhaps we can be of some help with respect to the Mirtazapine in terms of general drug information andl reinstatement principles:

 

Tips for tapering off quetiapine (Seroquel)

 

About reinstating and stabilizing to reduce withdrawal symptoms

 

Taking a look at your Mirt option analysis:

 

On 1/28/2023 at 3:44 PM, jackp said:

I could try and reinstate at a lower dose this time e.g. 1.8mg or alternatively for the first night I can take a higher dose e.g. 4.5mg to verify that this will work (the 5.5mg dose showed instant improvement within the first night during my first withdrawal attempt) and then subsequently lower the dose.

 

We recommend reinstating at the lowest dose possible to lessen the risk of overwhelming your brain with too much of the drug and causing a Humpty-Dumpty destabilization.  You don't have the same brain as when you last reinstated at 5.5mg, and there's no guarantee it will respond the same way it did the last time.

 

On 1/28/2023 at 3:44 PM, jackp said:

I am afraid if my dose is too low or something is off with the Mirtazapine timing, that I may only receive partial resolution of withdrawal symptoms but at the cost of my body once again becoming reliant on Mirtazapine. This would undo all the progress I have currently made in withdrawing and extend the duration of my withdrawal symptoms.

 

This is the classic conundrum, whether to seek relief and go back on the drug and have to later taper and in the process forfeit the progress you've made (and with no guarantee of success) -- or to grit it out without the drug but with no idea of how long it will take for you to stabilize.  

 

On 1/28/2023 at 3:44 PM, jackp said:

I am still a bit confused as to why my withdrawal symptoms only became so severe after dropping from 3.75mg to 0mg, but not during any of my tapers from 45mg to 3.75mg.

 

This is also classic and something we hear about frequently.  Members have reported little difficulty in large reductions at the higher doses, only to be unexpectedly slammed with withdrawal once they get to the low doses.  It likely has to do with receptor occupancy.  Our rule is, the lower you go, the slower you should go.  The graphs in this topic might help to explain the reason for this:

 

Why taper paper: dose-occupancy curves

 

On 1/28/2023 at 3:44 PM, jackp said:

Given this is not clear and I do not know what will happen as I slowly taper off again at these lower doses, I am a bit hesitant to get back on the drug. 

 

Is this you answering your own question?

 

This is your introduction topic -- the place for you to ask questions, record symptoms, share your progress, and connect with other members of the SA community.  I hope you’ll find the information in the SA forums helpful for your situation.  I'm sorry that you are in the position that you need the information, but I am glad that you found us.

 

 

 

 

 

 

 

 

 

Edited January 29, 2023 by Gridley

[jackp]

Hi Gridley, 

Thank you for the information this has been quite helpful. It's good to know it's common for lower doses to produce greater withdrawal effects as this was quite confusing for me. I will take your advice and reinstate around 2-2.5mg tonight to see how my body reacts. From there I can change the dose up or down based on my response and then stabilise. If this doesn't work, I guess I will just have to tough out the symptoms. 

 

5 hours ago, Gridley said:

Is this you answering your own question?

 

No it's more so just my concern around going back on a drug that has caused me so many issues. Part of me wants to just stay off it and get it over with, but given my pre-existing circadian rhythm issues, I think it will be safer to try reinstatement as I can always stop the reinstatement in a week or so if I don't get adequate symptom resolution. Hopefully that week doesn't extend my withdrawal symptoms for too long.