User1021: Mirtazapine withdrawal & reinstatement (looking for advice)

[User1021]

Hello,

 

New here. My primary issue is with the rollercoaster I’ve been going through with my antidepressant, Mirtazapine:

 

History: I’ve been on Mirtazapine for several years, very happy with the effects on my depression, appetite, sleep, and even anxiety to an extent. It’s efficacy has been consistent for me, such that over the years, I’ve only needed to increase the dose modestly once (from 15 mg to 22.5 mg, a switch made ~1 year ago).

 

The problem: just before the holidays 2023, I unknowingly used a counterfeit THC cartridge (don’t know what it was, but it was NOT THC), which properly thrashed my mental stability. After two weeks of distress - loss of appetite, cold sweating, bouts of heart racing, feelings that there is something very wrong (which put me in the hospital on two separate occasions, with “it’s probably just bad anxiety” being the punchline in both instances) - my psychiatrist thought maybe the Mirtazapine was worsening/prolonging the problem… So he cut me off cold-turkey. Knowing how effective it’s been for me, this was utterly devastating, but I indulged it, and we explored medication to calm my anxiety which, in short, did not stick >2 days (couldn’t handle the side effects). Moreover, after ~3 days without Mirtazapine, withdrawal started setting in - I literally could not eat (threw up everything I tried) nor sleep; I was intensely uncomfortable with a host of physical symptoms.

 

I touched base with my psychiatrist again, asserting that I was not convinced enough that the Mirtazapine was worsening things for this cold-turkey cutoff to be worthwhile. We decided to reinstate a small dose of Mirtazapine to feel things out (7.5 mg/day).

 

I’m now on day 3 of Mirtazapine reinstatement, and this is where I need feedback/help: reinstating the Mirtazapine has helped the majority of the most pressing symptoms; I can eat again, I’m sleeping okay, cold sweats/tremors/shivers have been largely resolved. What remains is: brain zaps (very pronounced days 1 & 2) and physical “jolts,” and today, an overwhelming feeling of pressure and heat in my head just after taking half of my 7.5 mg dose for the day - this was fairly scary, though I don’t have a fever at all (though it feels like I do), so I don’t think I am in a dangerous place. Otherwise, I’m feeling okay; my head is just in profound discomfort almost constantly, and this discomfort has made my eyes a bit twitchy, also scaring me.

 

I am absolutely torn in that I have no idea if this discomfort is a result of the Mirtazapine itself, or a continuation/evolution of withdrawal symptoms as a result of my current dose not being near that which I was on for many months (& on the other end of 3 days without entirely). This being unclear makes it really difficult to trust a further reinstatement of Mirtazapine to a place closer to my normal dose, as I’m terrified it’s going to manifest something serious physically. I don’t know how to approach this with my psychiatrist without threatening another rugpull on the Mirtazapine entirely, which I know only gets worse before it gets better (I would want to do a supervised detox if pushed this direction).

 

I am frustrated. I thought maybe bringing back the Mirtazapine would alleviate things, but now I don’t know if it’s the problem or the problem is I’m not taking enough.
 

Any insight/suggestions for how to approach this are much appreciated.

Edited January 8, 2024 by FireflyFyte
Updated title

[LotusRising]

Hi @User1021

 

Welcome to SA,

 

We are a peer-run volunteer site dedicated to a harm reduction tapering approach in an effort to minimize withdrawal symptoms. Our focus is on helping people taper off their medication. Stopping cold turkey is not something we recommend. We suggest tapering by no more than 10% of your most recent dose each month.

 

Could you help us out by adding a signature, which will ensure your drug history appears at the bottom of every post, making it more efficient for those trying to assist. 

 

How to Create a Signature 

 

These two links will help you to understand withdrawal syndrome:

 

What is Withdrawal Syndrome?

 

Video on Recovery from Psych Drugs

 

How long were you off mirtazapine before you were reinstated?

 

Please post any updates or questions related to your specific situation right here in your thread. It's helpful to keep everything related to your tapering journey in one spot and it helps to keep the site tidy. 

 

 

 

[User1021]

1 hour ago, LotusRising said:

Hi @User1021

 

Welcome to SA,

 

We are a peer-run volunteer site dedicated to a harm reduction tapering approach in an effort to minimize withdrawal symptoms. Our focus is on helping people taper off their medication. Stopping cold turkey is not something we recommend. We suggest tapering by no more than 10% of your most recent dose each month.

 

Could you help us out by adding a signature, which will ensure your drug history appears at the bottom of every post, making it more efficient for those trying to assist. 

 

How to Create a Signature 

 

These two links will help you to understand withdrawal syndrome:

 

What is Withdrawal Syndrome?

 

Video on Recovery from Psych Drugs

 

How long were you off mirtazapine before you were reinstated?

 

Please post any updates or questions related to your specific situation right here in your thread. It's helpful to keep everything related to your tapering journey in one spot and it helps to keep the site tidy. 

 

 

 

Thank you for the speedy response - I’ve added my history to my signature.

 

Off Mirtazapine for ~3 full days (took last dose on Monday, reinstated at 1/3 dose this past Friday).

 

I agree cold-turkey was a very ill-advised move, however the decision to do so was complicated by some level of concern that the Mirtazapine had been working against me amidst whatever the other thing has done to me mentally. Now I seem to be bouncing between withdrawal symptoms and possible side effects of the Mirtazapine upon reinstating (which sounds bizarre even to me, but would perhaps explain this weird sensation in the head? Tough to say…), or just a continued/worsening withdrawal because I’m only taking 7.5 mg (versus my usual 22.5).

 

It’s possible I’ve just been scared into believing that the reinstatement of the Mirtazapine itself could be making things worse, when it seems unlikely this is the case..? I have a lot of anxiety around trying to reinstate a dose closer to my standard, given how I’m feeling now, even though that might help quite a lot.

 

I live alone, so the scenario where it does make things worse and I experience more severe adverse physical effects is particularly worrisome.

[LotusRising]

@User1021

 

If it's only been 3 days, it's quite possible it's not enough. That's a huge cut to your dose. You may be experiencing symptoms after taking your dose because your body recognizes the lack of drug. 

 

You were stable on your dose of 22.5mg prior to the THC cartridge mishap?

[User1021]

11 hours ago, LotusRising said:

@User1021

 

If it's only been 3 days, it's quite possible it's not enough. That's a huge cut to your dose. You may be experiencing symptoms after taking your dose because your body recognizes the lack of drug. 

 

You were stable on your dose of 22.5mg prior to the THC cartridge mishap?

That sounds very possible… It felt like taking the drug again was something of a “shock” to my (already unstable) neurochemistry. Maybe I am just going through some re-acquaintance struggles that will pass the longer I continue? Hopefully something like that.

 

I was indeed very stable leading into this situation, which makes it doubly frustrating that it’s been so hard to overcome, even with the assistance of that which was keeping me so stable.

 

At this point I’m just desperate to feel “normal” again.

 

 

[Rhernan]

I cold turkeyed off mirt a few years ago and had to reinstate it.  I was only on 3.75 mg’s when I cold turkeyed and reinstated to 1.75 mg’s (I know, very low doses but it helped me a lot).  I recall that it took about a week (or more) to finally stabilize.

 

also, along my taper journey, there were several times I had to updose and I always felt like it was poisoning me the first few days to a week after updosing and then things settled.

 

Since it’s only been 3-4 days since you reinstated I think you should wait and see if you stabilize and if after a week, then SLOWLY increase your dose.  You can also make a liquid with pills and this makes going up in small increments easier and also can help you taper if you ever decide to come off.

 

if you need help with a liquid let me know, I used to do that before I did a compounding pharmacy here in the US.

[User1021]

1 minute ago, Rhernan said:

I cold turkeyed off mirt a few years ago and had to reinstate it.  I was only on 3.75 mg’s when I cold turkeyed and reinstated to 1.75 mg’s (I know, very low doses but it helped me a lot).  I recall that it took about a week (or more) to finally stabilize.

 

also, along my taper journey, there were several times I had to updose and I always felt like it was poisoning me the first few days to a week after updosing and then things settled.

 

Since it’s only been 3-4 days since you reinstated I think you should wait and see if you stabilize and if after a week, then SLOWLY increase your dose.  You can also make a liquid with pills and this makes going up in small increments easier and also can help you taper if you ever decide to come off.

 

if you need help with a liquid let me know, I used to do that before I did a compounding pharmacy here in the US.

Hi Rhernan - thank you for sharing your experience with it. It is reassuring to know that it also took you a bit to stabilize even after reinstatement. I think I'll give it a few more days at this partial dose, even if it means longer withdrawal as I adjust to it (I think as mentioned I'm simply too unstable to be comfortable going any higher right now, even if it might help). If I can get to a slightly more stable state in the next few days, cautiously trying to go up to 11.25 mg or so might be my next move.

 

Could you provide details about how to go about preparing and accurately dosing a liquid solution when you get the chance? I think that might help in this scenario.

[Rhernan]

22 minutes ago, User1021 said:

Hi Rhernan - thank you for sharing your experience with it. It is reassuring to know that it also took you a bit to stabilize even after reinstatement. I think I'll give it a few more days at this partial dose, even if it means longer withdrawal as I adjust to it (I think as mentioned I'm simply too unstable to be comfortable going any higher right now, even if it might help). If I can get to a slightly more stable state in the next few days, cautiously trying to go up to 11.25 mg or so might be my next move.

 

Could you provide details about how to go about preparing and accurately dosing a liquid solution when you get the chance? I think that might help in this scenario.

Yes, agreed, I think waiting it out at your current dose and seeing if things slowly improve is your best move at this point.

 

as for the homemade liquid you take your 15 mg pill and crush it up as finely as you can.  Once crushed well you take 7.5 mg’s of water and 7.5 mg’s of maple syrup.  (You need a solution that will help disperse the crushed up pill evenly and syrup does this.  There is also solutions available online, like OraPlus, that also work too).

 

once you have the water and syrup you add your crushed pill and shake very very well.  Then you draw up your dose with a syringe.  So your dose is 7.5 mLs. The rest you throw away as the homemade liquid won’t last long.

 

Another  alternative is to half your 15 mg pill to 7.5 and crush is and then do 3.75 mg’s water and 3.75 mg’s syrup.  This way your saving a 1/2 pill and won’t waste them.  This might me harder as it’s not a lot of liquid to work with.

 

There is also a support group on Facebook that I am part of that has all these directions and lots of help and info.  They were a lifesaver, along with this group too.  
 

 

[LotusRising]

@User1021

 

I can't say for sure what to do in your situation since the THC mishap is a confounding factor, but as I mentioned, this is a big drop in your dose. You may feel better at a dose a little closer to the dose you CT'd from. The alternative is waiting for your body to adjust to the dose you're at. 

 

Have you read our topic on reinstatement? Reinstating and Stabilizing

 

You might find the below two links helpful as well:

 

Tips for Tapering Mirtazapine

 

 

Please let us know how you're doing. 

[User1021]

1 hour ago, LotusRising said:

@User1021

 

I can't say for sure what to do in your situation since the THC mishap is a confounding factor, but as I mentioned, this is a big drop in your dose. You may feel better at a dose a little closer to the dose you CT'd from. The alternative is waiting for your body to adjust to the dose you're at. 

 

Have you read our topic on reinstatement? Reinstating and Stabilizing

 

You might find the below two links helpful as well:

 

Tips for Tapering Mirtazapine

 

 

Please let us know how you're doing. 

I've checked out the reinstating/stabilizing thread before, and am reluctantly considering the possibility that I'm experiencing that "kindling" phenomenon upon reinstating this smaller dose - it's just hard to distinguish whether it's kindling or a continuation of withdrawal at this point; I think time will only tell.

 

Will keep all posted on what's going on. I've touched base with my psychiatrist again today and we're going to see if I can stabilize at 7.5 mg and take it from there; I'm reassured in knowing that it's not necessarily surprising that I'm in this state given the combination of abrupt removal and reinstatement of it. I'm feeling somewhat better today; hopefully things just get better from here.

[LotusRising]

3 hours ago, User1021 said:

it's just hard to distinguish whether it's kindling or a continuation of withdrawal at this point

 

I would not think this is kindling, since you reinstated very quickly.

[User1021]

Hello all,

 

Just an update on this situation: I cautiously think things are improving significantly.

 

Had a bad night lead into a “good” day; couldn’t sleep so I took 2 mg of melatonin, still couldn’t sleep, even though my brain really wanted to be asleep - turns out this in combination with my body refusing to relax is a super uncomfortable state. Nevertheless, after a panic attack and 5 hours of trying, I got to sleep for a few hours. Felt bad this morning, but took half of my dose of the Mirtazapine (3.75 mg) which really improved everything. My appetite came back with a vengeance, I’ve been less shaky/sweaty/anxious, and although it’s definitely going to be tough to sleep again tonight, I am feeling okay for the moment. I took the other half of my dose just now, hoping for a smoother night ahead.

 

Here’s hoping this is a sign I’m stabilizing on this lower dose; I no longer think kindling is afoot whatsoever, I really think all of what I’ve been dealing with is looming withdrawal and/or the “growing pains” of trying to restabilize upon reinstatement of this smaller dose.

 

I say this all with serious caution, as I am worried about another wave of symptoms manifesting - will cross that bridge if it comes, I suppose.

 

Will update as things evolve.

[LotusRising]

This is an encouraging post  

 

2 minutes ago, User1021 said:

I took 2 mg of melatonin, still couldn’t sleep, even though my brain really wanted to be asleep - turns out this in combination with my body refusing to relax is a super uncomfortable state.

 

Do you mean with the melatonin? This is a little high of a dose. You could try a smaller amount, more in line with what your body produces, 0.25-0.50mg. You might notice a different effect. 

 

I'm glad you got just a little bit of sleep, some is better than none!

 

Were you dosing twice a day previously?

 

 

[User1021]

Just now, LotusRising said:

This is an encouraging post  

 

 

Do you mean with the melatonin? This is a little high of a dose. You could try a smaller amount, more in line with what your body produces, 0.25-0.50mg. You might notice a different effect. 

 

I'm glad you got just a little bit of sleep, some is better than none!

 

Were you dosing twice a day previously?

 

 

Yeah the 2 mg of Melatonin was definitely poorly judged, especially as someone who doesn’t typically use it at all. I took 1 mg ~8:30, trying to sleep by 9:00~10:00, and when I was still up (albeit tired) at 11:30 took the other 1 mg - the second dose had my brain and body pretty unhappy. I’m going to see how I can do without it tonight, and may try something like 0.25 mg if it doesn’t work out. Though, I didn’t get all that much sleep last night (~4 hours or so), so I’m kind of tired already, and hopeful it won’t be necessary - we will see.

 

I split the Mirtazapine dose today and yesterday, mainly because I wanted to be awake and aware of how my body was reacting to it immediately/was scared of being asleep through a bad physical reaction and therefore “missing” it, so I wanted to take some in the day to feel things out, even if it means a bit of grogginess. This isn’t typical nor ideal, surely, so if tonight works out, I might feel comfortable enough to take the full 7.5 mg at the appropriate time again tomorrow.

 

Really appreciate the encouragement through this - I’m definitely savoring the wins (being able to eat and sleep at all are big ones, knowing it could be much worse).

[User1021]

Another daily update: things are looking good.

 

Got a full 8 hours of sleep last night with no need for Melatonin or anything. Didn’t feel great when I woke up, but toughed out a few hours of anxiety/shakiness/sweatiness and ate something and was able to shake it off. Felt good enough to go out and hang around the laboratory I work in (I’m a STEM graduate student) and join in celebrating a lab-mates birthday. Still looming are waves (15~30 mins in duration) of fairly intense, unprompted anxiety, that I’ve been able to stay “in control” through; had a handful of these moments today. Compared to the previous few days, this is something I can tolerate. My appetite is still good, happily ate lunch and am ready for dinner, and I haven’t split my 7.5 mg dose today. Going to try sticking to appropriate dosage timing tonight.

 

Definitely feeling more and more assured I’m stabilizing the more days that pass that things don’t get worse.
 

Perhaps most importantly: I’m finding enjoyment in things again; talking to friends, revisiting my at-home hobbies, eating good food, thinking about the science I do, watching TV/movies - the things that my anxiety- and worry-ridden brain simply could not appreciate since starting this adjustment to the Mirtazapine. That feels so good that it nearly brings (happy) tears to my eyes.

 

Hoping further updates continue in this positive direction. Not out of the waters yet, but I am nearly functional again and so glad about it.
 

I will continue to post updates here until I’ve fully stabilized (or anything changes drastically), mainly so that folks who may be amidst comparable situations can perhaps stumble into this potential “success” story in-progress and push through their own challenges.

 

Turns out it does get better.

[User1021]

8-day post-reinstatement update:

 

Much of the same over the last two days, with glimpses of total relief and some waves of problems. Brain “zaps”/pressure/general discomfort in my head and body have somewhat returned and are pretty much the only thing I’m dealing with. Anxiety has been okay, haven’t had any full-blown panic attacks or anything, but definitely still “fragile.” I would say I’m at ~60% full power at this point, just trying to rest through this weekend; trying to do things this week definitely took a lot out of me. I’m hoping to be able to ramp things up after the holiday Monday.
 

Good things: still finding enjoyment in things through moments of discomfort, people around me have made note of my improved attitude/mood. Appetite is still really good; I lost quite a bit of weight through the worst of this experience which I am trying to recover. Still sleeping okay, but have woken up at odd hours through the last two nights, with varying success in getting back to sleep quickly (still avoiding any additional assistance with this, so maybe to be expected).

 

I’ll touch base with my psychiatrist on Tuesday. Might be ready to go back up a bit on dosage, and given that I’m pretty convinced what’s left is still withdrawal/adjusting to a lower dose, I’m hoping pursuing this can kick the last bit of symptoms.

 

We will see.

[User1021]

11-day post-reinstatement update: trying to kick up the dose…

 

Unfortunately had a pretty wicked migraine take hold Saturday night through Monday (yesterday) afternoon which has kind of clouded my ability to assess progress on overcoming recent challenges re: Mirtazapine. However, today has been pretty good. I have a ton of energy and am back in the mood to “get my (you know what) together” - cleaned up my whole apartment and did several loads of long-overdue laundry today; little things that are actually deeply gratifying considering how long I felt totally incapable of doing them. Like the last update, the only things still looming are some minor brain “zaps” and a still-tolerable level of anxiety which has been coming in waves.
 

Feeling confident enough that these are remnants of withdrawal from the 22.5 mg to 7.5 mg downtick (& intervening 0 mg days), my psychiatrist & I have decided to try restoring a higher dose. I’m going to try 11~12 mg tonight (they come to me in 15 mg scored pills, planning on taking a half and cutting the other half in half with a pill cutter - this might not be perfect, hence 11~12 mg). We are hopeful, given how much reinstating 7.5 mg has helped most of the other effects of the withdrawal, that going up gradually might be the key for overcoming these last bits of struggles.

 

Feeling optimistic; the metaphorical light at the end of this particular tunnel feels closer each day. At this point I think the end game is to stabilize back at 15 mg or so (in due time) and see how that sticks.