shaggy: SSRI veteran tapering Citalopram

[shaggy]

Hi all!

 

TLDR: Began taking SSRIs for GAD & depression at age 21 (now 42). Made a few terrible and uneducated failed attempts at discontinuing and each time reinstated due to depression symptoms. Now I'm more equipped and tapering again. At the time of this intro writing, I'm two months in.

 

Initial questions for the community:

 

1) Do discontinuation symptoms get better with lower volume dosage drops? I understand the 10% of previous dosage reasoning but I'm curious/hopeful that once dosage drops are say around .1ml, the symptoms will lessen compared to the current .4 ml. It's daunting to imagine living like this for multiple years.

 

2) What (if anything) helps alleviate the general symptom of a hyperactive sympathetic nervous system?

 

3) Do others experience an increase in appetite? I'm often hungrier and eating more since tapering. I am, however, exercising harder as it helps my symptoms so I can't tell for sure but I suspect the hyperactive nervous system is increasing my metabolic rate. This is more out of curiosity, I'm not gaining weight or concerned.

 

Full story and findings along my journey:

 

It began in college with depression. I was prescribed Paxil to help with my anxiety that was causing the depression; or at least that was how my PCP and psychologist explained it to me. It worked, quite well. Fourteen months later I simply decided to stop taking it, cold turkey. Within a couple months, my depression had returned and I couldn't bear it. I reinstated. I attempted again about 18 months later, this time with a taper of about two months. And again, within a few months of stopping, I was soaked in depression. I reinstated and this time with Lexapro due to my doctor saying he felt it treated anxiety better. I went about 9 years on the Lexapro before yet another attempt to discontinue. This time I tapered for four months, cutting tablets and/or skipping doses. I thought I had it all figured out this time, not knowing ****. Big surprise, the depression returned within a couple months of stopping. I tried to push through for a few months before reinstating. I was blown away that within 2 days of reinstating, I went from very depressed to feeling 100% normal, compared the 3+ weeks SSRIs typically need to change mood. It was as if my brain knew exactly what to do with its old friend. On or off the drug, anxiety was still an issue so I worked hard building up my toolset. Exercise, CBT and mindfulness based meditation have become the cornerstones of my mental health journey.

 

By this point, I solidly believed a state of depression was my baseline. I believed I'd be on SSRIs the rest of my life. I'm okay if that's still the case. But I don't love that. I hate the idea that I need a drug to feel "normal". I fear the stigma of using a psych drug and have only told a handful of people over the two decades I've used. I'm ashamed. I also fear the long term effects on my health, or that I'll someday be in a nursing home and someone will simply stop giving me my SSRIs and I'll be totally ***** and nobody will know why. Or maybe that's just anxiety, depression's drinking buddy, talking.

I continued honing in my anxiety coping skills over the years, with no plans to discontinue again. Then I started hearing about the research that SSRIs, while great at treating depression, are actually not good at all at treating anxiety. That there's way more to it than serotonin. All along, I believed the pill was just preventing my anxiety from getting so bad I became depressed. What if that security blanket wasn't actually that helpful? Or at all. What if my stronger resilience would give me a shot at success without drugs? Then I heard about people (likely this community) having success with very slow tapers and that there were liquid forms of the drugs. It still took me a few years to get curious and brave enough. I happened to read the book Dopamine Nation and she discussed Tardive Dysphoria, essentially where the ongoing use of SSRIs actually makes you depressed. Even though it's not that common, the evidence and a possible successful route to discontinuation made me to decide to give it another go. And what if what I considered to be depression relapses each time I dropped the drug before, was simply a discontinuation side effect given my insufficient taper?? I CAN DO THIS.

 

This taper:

 

I started out with my spreadsheet and excitement to get off the meds in 12 months. I was stoked. I knew, again from Dopamine Nation, that it takes about four weeks for the brain to balance out after a chemical change, so I had scheduled four-week drops. Then I start googling to be sure and found this site and the research behind the 10% taper. Even though my first drop was only 8%, I switched over to the 10% in the next drop. Now I've dropped twice, currently at 3.7ml/7.4mg or 74% of my original 10mg dose. Admittedly, I'm surprised how strong the discontinuation symptoms are this time around. I really only recall a lot of vertigo and sexual sensitivity when decreasing dosage prior. But I also have much stronger awareness now and mostly experience a hyperactive sympathetic nervous symptom with this taper. Not unlike taking a steroid for a sinus infection or drinking too much coffee. Some irritability and difficulty concentrating. Sound sensitivity. I've also had what I'll call fragmented sleep, I wake up in the middle of the night with my brain seemingly wide awake, yet I fall right back to sleep. I wouldn't call it insomnia albeit very annoying. The nervous system stuff can be really intense but it's not debilitating; I still go on doing whatever it is I would normally do. I believe I can kick this, and most importantly, without depression on the other end. I am a little bummed about the idea of it taking years, but I will not rush this.

 

What makes my symptoms worse:

 

Alcohol - I allow myself to have one drink per day, 3-4 days per week, right now. If I have two or more, it seems to trigger a wave when it wears off.
Caffeine - I've always been caffeine-sensitive but it's crazy right now. I usually can't even have a cup of green tea without feeling the nervous system ramp up. The thought of a cup of coffee...well I might as well take speed.
Lack of sleep - goes without saying.

 

What makes my symptoms better:

 

Exercise - I can be in a really sh*tty wave and not particularly feel like working out, but go to a 60 minute HIIT class and I'm golden the rest of the day. Intense exercise is amazing right now.

 

They're not evil:

 

I also just want to say for fellow members, SSRIs aren't the devil. If it weren't for them, I may not be here today so I owe a lot of respect to them. They can be immensely helpful.

 

--

Thanks for reading. This community is certainly helping me. Feel free to comment or question any of the above.

[Gridley]

Welcome to SA, shaggy.

 

Let me try to answer your initial questions.  

 

16 hours ago, shaggy said:

Do discontinuation symptoms get better with lower volume dosage drops?

 

1)  Depends on the person but maybe not.  It could be ups and downs (but definitely some ups) all the way to the finish line.  I think the answer lies in the SERT occupancy levels (link follows), which is how much of your neurotransmitters have been taken hostage by the drug and how fast they come back online as you taper.  They come back online percentage-wise much moreso as you decrease at the high doses (i.e., on the road back to normal) but it's almost a straight line down (not much decrease in SERT occupancy) at the lower doses all the way down to zero.  What this translates to is continuing adaptation to being back to normal (not a hostage anymore) which translates to ongoing withdrawal "growing pains" as you set yourself free.  That's why we say, the lower you go, the slower you should go.  The graphs in this chart might help explain the reason for this.

 

Why taper paper: dose-occupancy curves

 

I saved a comment by a member about low-dose symptoms and found it helpful.

 

"I read the serotonin transporter occupancy study I think back before even starting my taper and I immediately saved it as a PDF! It helped me understand the impact of dropping to zero and how the decline is exponential when one reaches 4, 3, 2,  and <1mg. The study was groundbreaking in my opinion in terms of explaining patterns as it seems to corroborate the anecdotal evidence from people here experiencing a shock when they hit the low doses and zero. This is why I mentioned earlier my plan to slow down at ~20% (4mg)."

 

Another helpful comment:

 

"Basically, a study they did in 2004 found that the Serotonin Transporter Occupancy was about 80% when taking a 20mg dose and still nearly 50% at a 3mg dose.   Even at a 1mg dose, the occupancy was nearly 25%!"

 

And another:

 

"Some people find that they have to slow down a great deal as doses get below 1 mg. This seems to happen with a few specific drugs, escitalopram (Lexapro) being one of them."

 

Since Citalopram is the direct cousin (descendant, really) of Lexapro, the previous comment is likely applicable.

 

16 hours ago, shaggy said:

2) What (if anything) helps alleviate the general symptom of a hyperactive sympathetic nervous system?

 

We don't recommend a lot of supplements on SA, as many members report being sensitive to them due to our over-reactive nervous systems, but two supplements that we do recommend are magnesium (glycinate is a good form) and omega 3 (fish oil). Many people find these to be calming to the nervous system.  Add in one at a time and at a low dose in case you do experience problems.

 

Magnesium, nature's calcium channel blocker 

 

Omega-3 fatty acids (fish oil) 

 

Then there are many, many non-drug coping skills found in our Symptoms and Self-care forum that you can link to on our many page.   I'd take a look there and see what might help.  Time is the cure.
 

3.  Regarding appetite, depends on the person.  Mine decreased, others report increases.

 

16 hours ago, shaggy said:

Fourteen months later I simply decided to stop taking it, cold turkey. Within a couple months, my depression had returned and I couldn't bear it. I reinstated. I attempted again about 18 months later, this time with a taper of about two months. And again, within a few months of stopping, I was soaked in depression. I reinstated and this time with Lexapro due to my doctor saying he felt it treated anxiety better. I went about 9 years on the Lexapro before yet another attempt to discontinue. This time I tapered for four months, cutting tablets and/or skipping doses. I thought I had it all figured out this time, not knowing ****. Big surprise, the depression returned within a couple months of stopping.

 

"Depression returned" or "return of the underlying condition" is what the psychiatrists would say.  We would say they are misdiagnosing and missing the elephant in the room: withdrawal, one of the major symptoms of which is depression.  As you know, we recommend tapering no faster than 10% of your current dose every four weeks.

 

Why taper by 10% of my dosage?

 

Here's some information on withdrawal.  You might already have read some or all of this, but in case you haven't...

 

What is withdrawal syndrome.

 

Brain Remodelling 

 

Video:  Healing From Antidepressants - Patterns of Recovery

 

Daily Checklist of Antidepressant Withdrawal Symptoms (PDF) 

 

The Windows and Waves Pattern of Stabilization
 

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.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

[shaggy]

Hi community!

 

It's been a minute, thought I'd give an update and pose a question. The taper is overall going well. I'm currently at 52% of my original dose and proud of that!! Some drops have been harder than others, but the overall trend seems to be more predictable & tolerable degrees of WD symptoms.

 

Question regarding insomnia. I'm now consistently waking after about 6.5 hours of sleep with a wired brain and can't get back to sleep. I typically need 8 hours of sleep and used to smash that no problem before tapering. I started taking the recommended Life Extension Melatonin IR/XR - Immediate & Extended-Release Melatonin 1.5mg & 250mg of Valerian Root a couple months ago. They helped me sleep consistently and through the entire night, for a while. The last few weeks though, I feel like I've regressed. 

 

Any recommendations? Any supplement changes to try?

 

Thanks!

[shaggy]

Hey all -

 

I have been steadily chugging away on my journey, originally reducing by 10% every four weeks and then at one point switched to 15% every five weeks and was able to bring that down to 15%/4 weeks. That's been working for me, meaning symptoms have been tolerable (albeit still relatively terrible at times). I also tried the brass monkey slide, which, with respect, didn't work well at all for me. I think the responses of multiple reductions were overlapping and compounding, it's not always clear when you're "over" the last reduction; week four can be incredible and then week five I'm a mess again. My current plan is to stick to the system, get to down to at least .185ml (Citalopram) and stop taking it if it feels right.

 

Today I spoke with my general practice physician to schedule some blood work, just to check in on my systems given all the sustained abuse I'm taking. He really challenged the method, stating I'm punishing myself each month with the dose changes and with such a low dose now (.61ml/1.2mg), I might as well cease completely. I know...this is the conventional wisdom you all and I have been told forever and I have a hard time believing I'm ready to just completely stop. According to Horowitz's findings, I've only moved from my full dosage ~70% SERT occupancy to ~30% today, so despite the low volume of medication, I have a ways to go.

 

But it did get me thinking, I've been successful with the 15% reductions and have often wondered myself if there's a certain level of impact to the nervous system with ANY reduction amount. Maybe I'd be better off with 20-25% reductions, over a longer period. It may take me just as long to get to zero but perhaps fewer steps to get there would result in less total suffering. I've read the stickies in the forums, that the nervous system wants slow and steady, but what's the marginal difference? I once reduced by only 4% and felt comparable symptoms.

I'm curious to hear from those who are or have gotten to these later stages and experimented with this.

With gratitude,

Shaggy

Introduction & background: 

 

[Emonda]

Hi @shaggy,

I've moved your new post back here. Please keep updating this thread so we can track your progress.

 

Only last night, I read in the Maudsley Deprescribing Guide that the lower you go, the slower you may need to go. I also recently heard Dr. Horowitz mention the same thing in an online Zoom presentation I watched. He mentioned that smaller doses have an incrementally larger impact on the receptors. 

 

I'd like to jump to zero too, but it's not worth rocking the boat.

 

I'd be sticking to the process that's got you this far.

 

Best wishes.

[shaggy]

Thanks, Emonda! Do you have the link to that online Zoom presentation? I'm guessing it's one I've seen but I'd love to make sure and maybe watch it again.

[LotusRising]

 

 

[shaggy]

Update: My most recent dosage reduction was in May and right around that time I noticed my symptoms all switching from somatic to psychological. Instead of irritability, noise sensitivity etc, I started having derealization & anxiety/panic. I decided to hold at that dosage (.52ml citalopram). I also started therapy and a host of other non-medical treatments. The derealization and anxiety/panic went away but were immediately followed by depression (this was my pattern pre SSRIs). Specifically anhedonia, poor mood, low energy, no motivation or initiative.

 

I then treated the depression with continued therapy, followed The Depression Cure & acupuncture. After about six weeks the depression completely cleared and I felt amazing. I also stopped taking melatonin early last week, after taking it for months on end. Now it's been three weeks since returning to a healthy and stable state (other than sleep still intermittently interrupted, especially the first couple nights without the melatonin supplement) and just when I was planning to reduce my dosage again, the depression just returned. Granted I've had some life stressors going into this week that I'm guessing triggered it, I normally wouldn't fall into depression over it.

 

So I plan to hold on my dosage but I'm starting to lose faith in my theory that the anxiety -> depression were part of the typical WD process. Going on three months at the same dose and seemingly two depressive episodes, how can I assess the state of my systems and be confident I'm ready to continue to taper. My psychiatrist unsurprisingly suggests the depression may just be my life with such a low dose. I refuse to believe it but I have my doubts.

 

Curious for others' thoughts and experiences with this.