Luciana: taper citalopram now? never?

[Luciana]

Full background: I took my first med (zoloft) in 2001. I tried many meds at that time. I was mostly on, sometimes off, a variety of different meds from 2004 to 2013. I was med free 2013-2017. Then I was talked into trying some newer depression drugs. Didn't stay on any of them. Then 2019 was the start of my current history - was briefly on escitalopram. But I couldn't sleep on it. So on to citalopram with a short break in between.

 

Citalopram background: I went on citalopram in about May 2020 and have been on it since then (mostly at 20 mg). I started at 20 mg and quickly went to 30 mg. I've made three attempts to come off and failed each time due to the increased depression being unmanageable. Landed at 20 mg after each attempt. No other withdrawal symptoms besides the depression. Now I understand my tapers were too fast. Each time I decided to go off, it was due to the drug being less effective than the year before, and each time I went back on, I didn't get as much relief as the last time I reinstated. 

 

Other info: I started a trial of rexulti in late May. In hindsight I see that my too fast taper made me so depressed that I was willing to try a med again even though it goes against my instincts. I came to my senses recently after some unpleasant side effects and decided to go off it. I will be fully off it by the end of the week. I will never try another psych med again. 

 

I have two questions to start with:

1. How stable should a person be to begin a taper? I am working full-time and managing day to day activities, but I am pretty depressed. There are several contributing factors:  chronic physical pain and fatigue I've had for years, traumatic childhood, loneliness, patterns of thinking. I have been in therapy for years. Do I just stay on this med forever even though it barely helps me (or maybe not at at all, I'm not sure) because I'm not stable enough to taper?
2. In terms of my recent taper attempt, is it better to give myself more time at 20 mg before trying to taper again? Or is it better to start it now since I only went back to 20 mg on May 7, so my brain may not be fully adapted to this new dose? I wish when I gave up on this taper that I only had gone back up to 10 mg. But I was feeling so desperate. Lesson learned. My tapers have been hard but not insurmountable until I pass that 10 mg threshold. 

[Luciana]

I've now read a little more about stabilization and reinstatement. I now understand that stabilization refers to withdrawal symptoms. But I'm still a little confused. My only withdrawal symptom is depression. Since reinstating to 20 mg, that has improved. It's hard to say if I'm fully back to how I was feeling before I began my taper. Perhaps not. But definitely better than I was before I went back up. It's hard to say because even pre-taper, I was pretty depressed (that's why I was convinced it made sense to try tapering again -- the drug doesn't work). 

 

One other thing to note: I have has some minor sleep issues since reinstating, but I reinstated close to the time that I began the trial with rexulti. So I don't know which is responsible. If it's the citalopram, I interpret that as just an effect of brain adapting to it again. I got sleep issues when I first started the drug. 

 

I'm not sure that I would gain any more stability by waiting longer. The drug just doesn't do that much for me anymore. 

But I am also nervous about tapering now. So I eagerly await advice. 

[Altostrata]

Welcome, @Luciana

 

You're currently taking 20mg citalopram? When did you take Rexulti, and at what dosage? What effect did Rexulti have? Please add the Rexulti information to your signature.

 

On 6/13/2023 at 11:24 PM, Luciana said:

My only withdrawal symptom is depression. Since reinstating to 20 mg, that has improved.

 

What was this "depression" like? How has your sleep pattern changed since reinstating 20mg?

[Luciana]

Yes, sorry for not explaining. I updated my signature. I am currently on 20 mg citalopram. Today is my last day of Rexulti, at about .075 mg (I didn't weigh it but I know it was less than a quarter of my .5 mg pills.) 

 

The depression for me when I got down to 6.25 mg citalopram involved more crying (though not every day), more emotional eating, low mood most of the time and painfully low mood some of the time, hating my life, decrease in exercise because too depressed to motivate. That said, I did still exercise at least 2x per week, I still got by okay at my job without anyone noticing. I still saw a friend about once a week and family about once a week, but it was much harder to motivate to leave the house. Oh also therapy became way less productive due to my low mood.

 

I'm not sure what changed my sleep pattern. My issue is waking up in the night and having trouble getting back to sleep. It's a symptom I have had on lexapro in the past. This time around it actually started the night before I started rexulti. That would be 5/25. So either that one night was a fluke, and all the nights from 5/26 to now have been because of the rexulti, OR that was the night that the 20 mg citalopram (which I went up to on 5/7) fully kicked in my brain. Your guess is probably better than mine. I guess once the rexulti is out of my system I'll know better. 

 

Thank you truly. 

[Altostrata]

I'm not going to be able to interpret your symptom pattern until some time after you stop making drug changes and reach a new baseline.

[Luciana]

12 hours ago, Altostrata said:

I'm not going to be able to interpret your symptom pattern until some time after you stop making drug changes and reach a new baseline.

I am off the rexulti as of today. Citalopram dose has been stable for over a month and I'm not making changes right now.

 

Can you tell me how long to sit tight before considering starting the citalopram taper? I'm just unclear if there is a set amount of time, or if it's once I've reached a point of normalized sleep again. But I'm not sure that will happen - the sleep is only mildly disrupted and who knows if it will improve.  Should I just check in with you in a month? Thank you. 

[Luciana]

Still had the sleep issue last night even with rexulti out of my symptom. 

My sense is that this is a citalopram updosing effect. I've realized from reading this site that new or historic side effects can appear when you updose. 

I will try to be patient, but I would like to start my taper soon so that I can sleep better. 

[Altostrata]

Since you changed 2 drugs at the same time, it's not possible to determine which might have caused your sleep problem.

 

16 hours ago, Luciana said:

Can you tell me how long to sit tight before considering starting the citalopram taper?

 

It will take 23 days from your last Rexulti dose for the drug to leave your system. Your symptom pattern will not be at baseline until then.

 

When did your sleep problem start?

 

You updosed citalopram to 20mg May 7, shortly before you started Rexulti on May 26. How did your symptom pattern change May 7-25?

 

How did it change after you started taking Rexulti?

 

What times o'clock do you take each of your drugs, with their dosages? Do you know that Adderall can cause insomnia?

 

To help us out, follow these instructions Please put your drug and withdrawal history in your signature You may need to use a computer to do this.

[Luciana]

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Since you changed 2 drugs at the same time, it's not possible to determine which might have caused your sleep problem.

I agree, I was just saying that my hunch is that it's the citalopram. 

 

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When did your sleep problem start?

It started May 25, the night before I began the rexulti. 

 

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You updosed citalopram to 20mg May 7, shortly before you started Rexulti on May 26. How did your symptom pattern change May 7-25?

The severe depression improved to some degree, though it took at least 2 weeks for that to start to change. Nothing else changed.

 

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How did it change after you started taking Rexulti?

I felt some increased fatigue. When I got up to 1 mg, I had eye twitching and a constant feeling of my eye being about to twitch. That is when I came to my senses that I didn't want to be on this drug. I began tapering off after two days of 1 mg. 

 

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What times o'clock do you take each of your drugs, with their dosages?

I had been taking adderall at 7:30 am, citalopram at 6 pm, and trazodone at 11 pm. When the sleep issues started, I experimented with moving my citalopram dose up to 1 pm, then 12 pm. I'm not sure right now if I should try even earlier or just go back to my 6 pm time. It's made no difference so far, and in the past when I had sleep issues on it, the timing didn't matter. 

 

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Do you know that Adderall can cause insomnia?

Yes, but I notice no difference in sleep for the days I take it vs the days I don't. 

[Altostrata]

1 minute ago, Luciana said:

The severe depression improved to some degree, though it took at least 2 weeks for that to start to change

 

How did this change?

 

1 minute ago, Luciana said:

I had been taking adderall at 7:30 am, citalopram at 6 pm, and trazodone at 11 pm. When the sleep issues started, I experimented with moving my citalopram dose up to 1 pm, then 12 pm. I'm not sure right now if I should try even earlier or just go back to my 6 pm time. It's made no difference so far, and in the past when I had sleep issues on it, the timing didn't matter. 

 

Prior to the sleep issue on May 25, had you ever skipped a dose of citalopram or trazodone, or taken them off-schedule? Had you taken Adderall 2 or more days in a row?

[Luciana]

2 hours ago, Altostrata said:

 

How did this change?

I'm not sure exactly what you're asking. But I'd say it eased up and I was back to either my pre-taper level of depression, or maybe just back to the level I felt when I was in the 10-15 mg range of my taper (hard to say). If you mean what did lowered depression look like for me, it's things not feeling quite so impossible, able to engage better in therapy, not crying much anymore, mood not as low and less emotional eating. 

 

2 hours ago, Altostrata said:

Prior to the sleep issue on May 25, had you ever skipped a dose of citalopram or trazodone, or taken them off-schedule? Had you taken Adderall 2 or more days in a row?

I only missed a citalopram dose once in three years (several  months ago). I don't skip trazodone because I need it for sleep. Citalopram timing is occasionally off by at most two hours. 

I usually take Adderall four days a week, and two of those days are consecutive. I had not taken it two days in a row on the 25th though.

[Altostrata]

14 hours ago, Luciana said:

I was back to either my pre-taper level of depression

 

What do you mean by "depression" at this level?

 

14 hours ago, Luciana said:

Citalopram timing is occasionally off by at most two hours. 

 

Inconsistent dosing of citalopram can result in odd symptoms, including insomnia.

 

14 hours ago, Luciana said:

I usually take Adderall four days a week, and two of those days are consecutive. I had not taken it two days in a row on the 25th though.

 

Why do you take Adderall on this schedule? In the week prior to the 25th, had you taken it 2 or 3 days in a row?