Biquelle: psychotic depression tapering

[Biquelle]

Hi,

 

relapse/recurrence &

types of withdrawal: new withdrawal symptoms, rebound, persistent withdrawal symptoms(PWS), post-Acute Withdrawal Syndrome (PAWS).

https://psychscenehub.com/psychinsights/diagnosis-and-management-of-antidepressant-withdrawal-the-hyperbolic-curve-and-ssri-withdrawal-2/

 

The course of psychotic depression is well described in literature however there is considerable variation between individuals.

 

I don't get withdrawal symptoms when reducing medication. However my attempts either 1) stop cold turkey (yes not a good idea) and 2) reducing hyperbolically over a year to 0mg  (first QUE 800mg then VENL 375 mg) resulted in a relapse 12 months later. This comes out of the blue with rapid onset which needed hospitalization. The 12 month period is almost symptom free.    

 

So what is this called and what is the underlying mechanism as I can't seem to find it back in the literature?

Is this a new type of delayed withdrawal? or just a natural occurrence and part of the course of the illness?

Tapering in psychotic depression is particularly tricky because of 2 medications. Yes 1 at a time, which one first,

Reducing to maintenance dose ( which I don't know as I have relapsed consistently) or infinitely slow and hyperbolic reduction over years.

 

The probability of success is only with hindsight. For some the risk is a too high price to pay.     

 

Biquelle.

Edited January 30, 2023 by manymoretodays
name to title

[Altostrata]

Welcome, @Biquelle

 

We cannot tell you what happened after you tapered off venlafaxine and quetiapine last year. Ordinarily, we recommend tapering only one drug at a time, and a gradual hyperbolic taper of 2 drugs would take more than a year.

 

It appears you have been taking psychiatric drugs since adolescence. We have seen that when people have a long history of switching drugs, taking drugs in combination, experiencing drug adverse effects and withdrawal, their nervous systems are sensitized to drug reductions and they need to taper even more carefully than the average.

 

Your signature indicates that if you tapered throughout 2022 and relapsed September 2022, you tapered both drugs over 9 months. I suspect you developed withdrawal symptoms sometime during your taper, which got worse afterward, until you reinstated your drug cocktail.

 

Are you feeling better now that you're taking your original dosages of venlafaxine and quetiapine? If you feel you need your drugs to control your condition, by all means, continue to take them.

[Onmyway]

Dear @Biquelle

welcome to SA and thank you for completing your signature. Can you please provide a bit more detail so that we can understand your case better. When did you complete your taper in 2022? How often and what percentage of your previous dose of your drug did you cut? 

 

Here is a paper that talks about reducing antipsychotics to minimize relapse in people with schozophrenia. I don't know what your diagnosis is but this is the one paper I know about reducing antipsychotics using SA's methodology. Hope you find it helpful.

https://pubmed.ncbi.nlm.nih.gov/33754644/

 

If you decide to taper your drugs again to 0 or to a different dose, we recommend tapering one drug at a time and cutting no more than 10% of your previous dose every 4 weeks with longer breaks/holds when symptoms intensify. You can have a look at the links in the first post of the thread below to help familiarize yourself with SA's knowledge on tapering. 

https://www.survivingantidepressants.org/topic/300-important-topics-in-the-tapering-forum-and-faq/

 

These are about your specific drugs below: 

https://www.survivingantidepressants.org/topic/1707-tips-for-tapering-off-seroquel-quetiapine/

https://www.survivingantidepressants.org/topic/272-tips-for-tapering-off-effexor-and-effexor-xr-venlafaxine/

 

Hope you start feeling better soon, 

OMW

Edited February 1, 2023 by Onmyway

[Biquelle]

@Onmyway

@Altostrata

See attached my responds.

OnmyWa_Responds.pdf

Edited February 4, 2023 by Biquelle
included @altostrato

[Biquelle]

@Altostrata

 

Thank you for your reply. I have also changed by signature with more details of medication history as a pdf.

 

See attached responds. I also send it to @Onmyway

 

 

[Altostrata]

Please type your information into your signature so it can be seen on every post.

 

Please put your responses into a post. As a rule, the staff does not download anything. For very complex documents, you can provide a link to Google Docs or other repository.

[Onmyway]

Hi @Biquelle

here is the link to how you can change your signature. 

 

[Biquelle]

@Altostrata@Onmyway

Thanks again for the guidance. I feel better now after re-initiation of med cocktail. Regarding medication I started using paratoxine when I was around 30 years and

not from adolescence. I am 48 now. I have update my signature as advised.

 

Ignore and delete my previously attached onmyway_responds.pdf. Too long and not to the point.

 

To my original question I think this is a good article regarding types of withdrawal classifications and symptoms.

 

What I know:

1) Once psychotic symptoms(delusions) occurred all subsequent acute episodes also had psychotic episodes.

2) Apart from the 1st episode all subsequent episodes had a rapid onset (out of the blue).     

3) Discontinuation Cold-Turkey. Relapse 6 months later preceded by Neuro-Muscular Sensory symptoms

4) Maintaining Max dose Medication after ECT kept me free of severe depression for 4 years.

 

5) Tapering over 1 year of 2 meds in a linear way (not hyperbolically!) caused relapse 6 months after discontinuation (the date of last pill). 

I ignored rapid onset withdrawal symptoms which are very similar to my underlying illness but no psychotic symptoms. I thought I had a relapse but somehow it felt different.

It occurred halfway tapering (6 months) which resolved in 8 weeks. Transient and rapid onset are important criteria for withdrawal. Ignoring and continuing tapering was a big no no. Lesson learnt. However I acknowledge it is incredibly difficult to recognize, if at all recognized, and may be absent in some patients. It can be very subtle.

 

I won't make an attempt to classify my symptoms as in the article above. I am not sure where I fit it.

 

It occurred to me that hyperbolic reduction is not the holy grail. It is a guideline based on receptor occupancy however everybody is different, some are in a med cocktail

with AP + AD, where the AP has an AD-effect too and we do not really know how AP and AD work in the first place. It is based on user experience and I have not seen clinical trials to prove the elegant and to good to be true method of hyperbolically reduction.  After all you still take a (calculated) risk. You can increase the probability of success but you will only know with hindsight if you are successful or not. e.g. I can do the perfect hyperbolic tapering to zero mg with zero withdrawal symptoms in x years but I get a relapse after 6 months. Is this because I increased the risk of relapse by tapering to zero mg compared to if I continued the medication without tapering or was the hyperbolic tapering not as perfect as I thought it was by not recognizing subtle symptoms. Similar to patients who do not recognize or dismiss subtle early warning signs months before a sudden onset of an acute episode. It is often that with hindsight patients say oh yes that was a bit strange that particular day.I seems patients forget the ugliness of their illness when in remission. Great discipline, insight and courage is needed to overcome all these obstacles. e.g. I am not if this recommended but I would not take 1 of the medication for a week and monitor what happens. For some it will work and for some it will mean acceptance that they may need a  (reduced) maintenance dose of the medication the rest of their life. There is a limited amount of experiments you can do and their is a lot at stake if things do not go as planned. Therefore it is critical to be prepared in case **** hits the fan indeed I can get nasty very quickly out of the blue.

 

The cocktail of meds doesn't make it easier :). If I try again

1)very very slow and robust hyperbolic plan,

2)go even slower when symptoms pop up.

3)Possibly only 1 of the 2 meds,

4)Possibly not reduce all the way to 0,

5)Increase period between reductions if necessary,

6) monitor symptoms carefully especially after a  reduction.

7) Realistically over years instead of 1 year.

😎 One at a time, but which one first?

9) Do an initial cut of 50 % as I am on high dose staying in 90% occupancy rate  and then taper?

[Onmyway]

Hi @Biquelle, 

the idea that AD withdrawal symptoms emerge quickly and later symptoms are relapse is just a conjecture. [I can't speak for APs, just ADs]

We find here that for some people withdrawal might not emerge for months (and it feels different from relapse sometimes). I am having a hard time with the idea of relapse for ADs given that in placebo controlled studies' meta-analyses they don't seem to be much different from placebos. More than 50% of studies submitted to the FDA for approved ADs were null or negative. 

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4172306/

 

Hyperbolic taper of 10% would take many more years. I have been tapering a single AD for 4.5 years now very slowly because I get symptoms if I go faster than 5%. You have been on many more drugs and so I'd recommend slow as well. 

 

I know nothing about APs so can't speak to that. 
OMW

[Altostrata]

Currently, what times o'clock do you take your drugs, with their dosages?

 

I'm not clear on what you want to do. If you think you need a batch of drugs for psychotic depression, we're not going to argue with you.

 

On 1/30/2023 at 5:08 AM, Biquelle said:

I don't get withdrawal symptoms when reducing medication. However my attempts either 1) stop cold turkey (yes not a good idea) and 2) reducing hyperbolically over a year to 0mg  (first QUE 800mg then VENL 375 mg) resulted in a relapse 12 months later. This comes out of the blue with rapid onset which needed hospitalization. The 12 month period is almost symptom free.    

 

So what is this called and what is the underlying mechanism as I can't seem to find it back in the literature?

 

We can't tell you what happened to cause you to "relapse". Lots of things might have happened over a year.

 

What we see here is that when people have a long history of psychiatric drug switches, going on and off drugs, and adverse reactions to drugs, their nervous systems might become sensitized to other drugs, alcohol, antibiotics, covid-19, or even foods and supplements. 

 

If you had additional drug switches during that year, or drunk alcohol, taken antibiotics, got covid-19, developed a sensitivity to certain foods and supplements, or skipped doses of any of your drugs or taken them off schedule -- any of these events might have precipitated a "relapse".

 

We see adverse drug reactions and withdrawal syndromes so often misdiagnosed as "relapse" here -- incidence is close to 100% of our membership, that's why they join -- personally, I take all your diagnoses with a grain of salt. Most likely, your doctors were too complacent to investigate an iatrogenic cause.

 

We don't use diagnoses here, we don't treat "mental illness", we help people taper their drugs. Much of recovery comes from the inner resources ignored or denied by psychiatric treatment and identity as a psychiatric patient.

[Biquelle]

 

@Altostrata

 

200 mg Quetiapine XL morning

375 mg Venlafaxine XL morning

 

600 mg Quetiapine XL evening

25mg Promethazine

 

It's just that I keep reasoning with myself to explain my symptoms with scientific evidence. However the more I read the more confused I get.

I find it difficult to deal with uncertainty especially the phase lag and the sudden appearance of withdrawal symptoms several months after discontinuing the medication.

I would be able to manage the withdrawal symptoms by going slower and increase the interval between reduction or put a pause for several months to decrease the risk only

to find out I relapse 6 months later. It might even mean this is actually not relapse but as suggested in literature the development of a entirely new

chronic persistent withdrawal syndrome altering  and/or interfering the course of the original underlying illness. If this is rebound or new withdrawal or protracted withdrawal is less important as I am individual and do not present an entire population. I am faced with a conundrum. It is like those moments you are trying to fix something and only make it worser. I still have hope and I won't give up although it is getting harder the older you get. Don't get me wrong as hyperbolic tapering is a brilliant insight but in some

cases caution is required.

 

 

[Altostrata]

That is an impressively massive drug cocktail.

 

Please specify times o'clock in your dosing schedule, such as "9:30 a.m.". If you are taking quetiapine at the same time as venlafaxine or promethazine, that could increase the risk of drug-drug interactions and adverse effects.

 

If your question is whether you might reduce one of your drugs by gradual tapering, the answer is yes. That is what we do here.

 

Since you're taking a large amount of quetiapine, and it is a drug with a lot of health risks, I might reduce that first. It is possible that you will find you can get by with a much lower dosage than you're taking now.

 

For background, see Tips for tapering off quetiapine (Seroquel)

[hayduke]

Hello @Biquelle.  You may wish to visit a clinical psychologist specialising in trauma and see if you have some root causes of your troubles you might work towards resolving.

I would look for someone who is across the work of Bessel van der Kolk, particularly "The Body Keeps The Score".

 

All the best.

[Biquelle]

@Altostrata

 

I have update the times in my signature. Yes I am very tolerant to the high dose. The the side-effects are annoying but bearable most of the time.

Quetiapine, see uploaded image, is a three stage rocket and worse venlafaxine Serotonin Norepinephrine Reuptake Inhibitor(SSRI Venlafaxine ) > 300 mg Dopamine too.

Some say the metabolite of quetiapine (norquetiapine) has the antidepressant effect. These multiple concomitant pharmacological actions of quetiapine and venlafaxine make it more interesting and challenging.However this is in theory and I am individual and do not represent the entire population. And then there is the other controversy  if psychotic depression is a severe subtype of severe depression or is it an entirely new illness. I develop psychotic depression very rapidly with the peak within a week. I literally can climb a mountain and the next week I am in hospital. Two weeks later I am out of the hospital and already titrated upwards to max dose. Then another 6 months to go in remission. For some reason I get psychotic symptoms when I am in the severest part of the depression (mood-congruent). I have cut down quetiapine from 800mg to 400 mg before in 50 mg steps per month and I had no trouble with that so it would make sense to do this again and when I reached 400mg keep it stable for a few months just to be safe as a relapse has disastrous consequences.. Obviously I have to watch any psychotic symptoms closely but I don't expect they will occur as they are mood-congruent. It is therefore important to monitor depressive symptoms very carefully. For the moment I will  not change any doses of venlafaxine. I guess the choice of tapering quetiapine first over venlafaxine is based upon the side effects and has become mainstream. However it is important to note there is no reason to believe I can do it the other way around. 400mg Quetiapine could have the same antidepressant effect as 375mg Venlafaxine and 800mg Quetiapine. But I have to make a choice so I will start with Quetiapine.

 

[littlebird]

Hi Biquelle! Welcome!! 

 

I take Quetiapine at night, and it knocks me out. I'm wondering how you manage taking it in the morning! How is that for you?

 

On 2/6/2023 at 3:58 AM, hayduke said:

I would look for someone who is across the work of Bessel van der Kolk, particularly "The Body Keeps The Score".

This is a seminal work, but a big ole trigger warning, if you have a trauma history (especially assault) this book can be pretty triggering. One of the first examples is about treated someone who committed assault, including what his assault was, mentioned quite casually. If that is not the particular trauma you struggle with, this book may be fine to read, but as someone with significant trauma, it wasn't the one for me. Also, he was fired from his own trauma center for mistreating employees!

 

The work of Peter Levine (Waking the Tiger) is presented in a much more careful way, and tends to be an easier read for those with trauma history. 

 

Glad you're here! It's a good place. 

[Altostrata]

@Biquelle please note that we caution extra care in tapering an antipsychotic such as quetiapine. If it is tapered too quickly, withdrawal symptoms resembling psychosis may occur in anyone, even those with no prior history of psychosis. 

 

It's very possible you will do fine with an initial 10% dosage reduction. Please let us know how you're doing.

[Biquelle]

@littlebird Indeed I take 200mg Quetiapine XL in the morning. The other 600mg in the evening.

I get slightly sedated in the morning but it isn't too bad. I was curious what would happen if I don't take in the morning.

I get very agitated and restless. The quetiapine in the morning was initiated in the hospital 5 months ago.

First as a prn 100mg (“as the situation demands,” or simply, “as needed.”) and titrated upwards to 200 mg.

I think because it is important to distribute it evenly throughout the day (24 hrs) as Quetiapine has a short half time.

But indeed worthwhile to investigate.

[Onmyway]

@Biquelle

I wonder if the morning quetiapine simply suppresses the  agitation (ADR?) created by venlafaxine if that's the reaction you get when you don't take it in the morning. 

 

Have you ever had therapy to understand if your psychoses have a root cause such as a trauma history? 

 

Have you read the book "Anatomy of an epidemic" by Robert Whittaker? He talks about "relapse" in people who have been medicated and those who have never been medicated for psychotic episodes. His findings are eye opening. 

 

OMW

[Biquelle]

@Onmyway

 

The psychotic symptoms are exclusively of the delusional type and are always the same theme(derogatory nature, intrusive thoughts, persecutory)

However I have no clue why and cannot relate them to any trauma. Some say the psychotic symptoms were already there phenotypically and it is part of a trade vulnerability

which exposes itself in later adulthood coinciding with the severest part of (untreated) severe depression. Once there they will appear in every subsequent

acute phase. Others say it has to do with the severity of the depression but not everybody gets psychotic symptoms even in very severe depression. Or

psychotic depression is just another illness evolving alongside and overlapping an existing depressive illness.

Yes therapists. One said you are not your thoughts. brilliant. The other you cannot do it alone. Equally brilliant. 

Might well be that i am suppressing my agitation with Quetiapine. This can be venlafaxine or a million other things. AD's & AAP's are incredibly complex and

even after 40 years still scratching the surface. Robert Whittaker: Yes I have seen him on madinamerica

[Altostrata]

11 hours ago, Biquelle said:

I was curious what would happen if I don't take in the morning.

I get very agitated and restless.

 

If you have been skipping doses of any of your drugs, or taken them off-schedule, this may have generated withdrawal symptoms that you might call agitated psychosis. Some of your problems might be iatrogenic.

[Onmyway]

9 hours ago, Biquelle said:

@Onmyway

 

The psychotic symptoms are exclusively of the delusional type and are always the same theme(derogatory nature, intrusive thoughts, persecutory)

However I have no clue why and cannot relate them to any trauma. Some say the psychotic symptoms were already there phenotypically and it is part of a trade vulnerability

which exposes itself in later adulthood coinciding with the severest part of (untreated) severe depression. Once there they will appear in every subsequent

acute phase. Others say it has to do with the severity of the depression but not everybody gets psychotic symptoms even in very severe depression. Or

psychotic depression is just another illness evolving alongside and overlapping an existing depressive illness.

Yes therapists. One said you are not your thoughts. brilliant. The other you cannot do it alone. Equally brilliant. 

Might well be that i am suppressing my agitation with Quetiapine. This can be venlafaxine or a million other things. AD's & AAP's are incredibly complex and

even after 40 years still scratching the surface. Robert Whittaker: Yes I have seen him on madinamerica

Hi @Biquelle

I hope you realize that all of the things that "some" say are conjectures without any proof - we simply don't have information to support any of that stuff. I am of the persuasion that things that our mind does make sense - that it is not just random. Sure thoughts and associations may occur as if out of the blue to us and sometimes things misfire but there is a reason why we get depressed (overwhelm for example). Trauma and our adaptation to stresses would produce extreme states. It doesn't have to be the trauma of war or sexual abuse, it could be the trauma of a rejecting teacher, of someone who yelled at you at age 3 and scared you etc., the relationship trauma of not feeling loved or neglected. 

 

Our brains are super adaptable to our environment and they can readapt to our new environment as well, to a sense of safety and healing. I loved the book "The Brain That Changes Itself" it talks about the plasticity potential of the brain. 

 

Sure, brains can be different from each other but fundamentally we strive towards survival, and healing and adapting to our environment. That is why when faced with similar challenges we react in similar ways - when people are kidnapped they may form an alliance with their captor to survive, when kids are bullied they may withdraw and be depressed and so on. 

 

Tell me that at the time you had your first depression things outside you were going great or that when you had your first psychosis life was peachy and all of a sudden you started worrying that someone is persecuting you, that there was no bullying, neglect, difficult family or peer dynamics and you felt fulfilled with life. 

 

What I am saying is that I do not believe that something is fundamentally wrong with you but suspect that you were put in overwhelming (for your level of development at the time) circumstances that your mind needed to make sense of and it made sense in a specific way which someone considered pathologic and tried to quash instead of trying to understand it and help it heal and adapt in a way that was safer, less threatening and less pathologizing. 

 

All these "some" who claim to know so much about these things have thrown countless drugs at you to see what sticks. Why? Because they have no clue under all that talk of neurotransmitters and phenotype and genotype. It is all BS. There may be a breakthrough in the future that clarifies things but a lot of psychiatry right now is pure BS perpetuated by self-important idiots clinging to their power over vulnerable people. [I have not been in a hospital but the stories I have heard are outrageous]. Psychiatry's history is littered by abject failure, deception, abuse of power. They have only recently found legitimacy in their medicines and are clinging to them by denying all the awful effects that they have incl. withdrawal. 

 

This reminds me of a doctor who told a friend who had had a psychotic episode that if she wore lipstick she would feel better. We called him Dr Lipstick after that and couldn't really take him seriously. My friend had had a psychotic episode after intense trauma - lipstick was so far from what she was even thinking about. 

 

Check out Pete Walker's website if you want to know more about complex trauma. 

http://www.pete-walker.com/fAQsComplexPTSD.html

 

We all choose to look at things a certain way - you can look at MH problems as diseased states caused as imbalance of neurotransmitters, genetics, imbalance of electrical signals, as immune issues, some even have blamed viruses or you can choose to look at them as a rational reaction to circumstances, as caused by social issues, or even evidence of religious experiences and so on. 

Similarly when you look at the sea you can see it as an ecosystem, you can see the physics of the waves, you can see the chemical composition of the water solution, you can look at the optical properties of various particles in it - it's a matter of perspective [my personal one should be obvious by now].

 

Some of these perspectives might lead to healing and some of them might be a good bandaid for a time but cause other issues. 

 

You seem like a curious, smart person who has dealt with quite a lot . It sounds so difficult to be going through all of what you have been and are going through now. I do hope that you find healing in some way and I hope to help in whatever way I can. 

 

If you do decide to taper, however, I would go very very slowly in your case because of the long history of possible iatrogenic harm. I know how scary it must be to not trust your mind. We want you to be as stable as possible throughout the taper - we want to minimize harm as much as possible. There are people here who have come off of medicines and with stories not unlike yours. Check out Shep's success story. 

 

Sending you hugs, 

OMW

 

Edited February 8, 2023 by Onmyway

[Biquelle]

@Onmyway

My parents divorced when I was 12. My first acute episode was when I was 38. Before that everything went seemingly well. I was a workaholic until everything imploded. I really did not recover from that. Although functional between successive episodes I felt mostly lost. This time around I am doing things which I find enjoyable, I can’t believe I am saying that, and do sociable stuff. I don’t have to pretend anymore. I can take it easy for a while keeping in mind I have to actively engage with the world around me. 

[Biquelle]

@Altostrata

 

I agree. I should not play around medication. Take medication at set times military style.