OlivePit: Citalopram poop-out, withdrawal, and switch to fluoxetine

[olivepit]

Posting on behalf of my partner who I am caring for through withdrawal and tapering. He is not in a good place to be on the internet much currently but we have questions and still need support, so I am posting for him (hope that's okay). Anytime I say "we", I am referring to my partner and I as we've discussed and strategized together.

 

Longer-form version of his drug history:

• 2008-2012:
  • Fluoxetine for 4 years during high school
  • Doesn't remember exact dose but likely 10mg
  • Had a really easy time discontinuing in 2012 when he wanted to stop taking it. Doesn't remember if he stopped cold turkey or did any kind of taper at the time
• 2016:
  • Fluoxetine 20mg for a few months, around age 21
  • Remember it being easy to start without bad symptoms from updosing
  • Was experiencing sexual side effects and stopped cold turkey
  • Remembers it being "medium" difficult to stop. Mostly some increased depression for a period after stopping, but nothing close to what he is going through right now with citalopram
• 2018-2020: 
  • Began citalopram 20mg for depression and anxiety after difficult life events. Wanted to avoid fluoxetine due to sexual side effects
  • Severe depression as side effect from updosing when originally starting. Remembers it being about a month of the worst depression he had ever felt up to that point, worse than the depression that led him to take it in the first place.
  • Then was at 20mg for a few years after stabilizing
• Jan - Mar 2020: 
  • Was feeling happy, wanted to discontinue citalopram.
  • Psychiatrist said the 20mg dose was so low that he could just stop cold turkey, but that he could do a few cut and holds if he wanted to be extra cautious.
  • After cutting to 15mg, was feeling agitated for months
• Mar 2020 - Jul 2023:
  • Decided to reinstate the 20mg citalopram and micro-taper
  • Got liquid form of citalopram and tapered from 20mg -> 5mg over a few years, with some holds along the way
• Mar 2023:
  • Began feeling regularly agitated. This was around the time of an injury and some other difficult life circumstances that challenged his mental health routine, so he thought maybe he needed a higher dose.
  • Bumped up to citalopram 7mg all at once
• Jul 2023:
  • Was still feeling regularly agitated. (In retrospect, we're pretty confident the agitation beginning in mar 2023 was poop-out)
  • Bumped up to citalopram 10mg all at once
  • This bump up was severely destabilizing. Began experiencing panic attacks, chest pain, and higher anxiety (had never had panic attacks or chest pain from anxiety before in his life, so these were brand new as a result of the updose).
  • Started taking hydroxyzine 25mg or 12.5mg regularly as needed to manage the heightened anxiety, and propranolol 10mg or 5mg very occasionally as needed to prevent/manage panic attacks
  • Determined the citalopram had probably been pooping out before bumping up. Made a plan with psychiatrist to switch to fluoxetine in the short-term to get off the citalopram, and then eventually taper off the fluoxetine since he had gentler reactions to fluoxetine in the past when starting & stopping
  • Plan was to make the switch in January 2024 - this was due to some planned life events that made it inconvenient to switch sooner, and because the poop-out symptoms seemed somewhat manageable in the short term
  • Around November-December, the poop-out symptoms were worsening again and we determined he needed to make the switch sooner
  • Psychiatrist was concerned about serotonin syndrome and did not want him to take fluoxetine and citalopram simultaneously. Instead they wanted him to do a clean switch, taking 10mg citalopram one day and then fully switching over to 10mg fluoxetine the next day (with 0 citalopram from that point on)
• Dec 21 - 25 2023:
  • Began the "clean switch"
  • Began feeling some moderate withdrawal symptoms after a couple of days
  • By Dec 25 the withdrawal became severe, both physically and mentally. During a peak wave of uncontrollable shivers, headache, nausea, chest pain, insomnia, severe anxiety and depression we decided to reinstate 2mg citalopram. Within an hour of reinstating the worst of the physical symptoms had significantly lessened - especially the shivers, headache, and nausea. The anxiety and depression also lessened.
• Dec 26 2023 - present:
  • Have been taking 2mg citalopram (1mg morning and 1mg nighttime), 10mg fluoxetine
  • Taking 25mg or 12.5mg hydroxyzine as needed, generally totaling about 37.5-75mg daily depending on the day
  • Also taking 0.125-0.5mg lorazepam occasionally as needed, not every day. Has been about a few days per week.
  • From Dec 26-Jan 2, it seemed like things were improving. We starting tracking FINISH a few times a day and he was doing better than he had been at the peak waves before we reinstated the citalopram.
  • But since January, most of the withdrawal symptoms have plateaued. The physical symptoms have improved a lot: headache and nausea are almost nonexistant now, and dizziness has steadied at a low-medium level. But ever since those lessened, he has been having more insomnia, and constant and severe anxiety daily, accompanied with chest pain and stomach pain, and occasionally a more severe bout of panic. This has also begun being accompanied with increasing depression, often at the same time as waves of panic or severe anxiety.
  • The depression is increasing day by day from the despair and exhaustion from the prolonged physical and mental pain with no improvement on any of the withdrawal over the last two weeks. For the first time in his life, this has brought on questions of his will to keep on trying during his worst waves. He is running out of steam and feeling very scared and demoralized.

 

Our immediate goal:

We want to try to get him stable on 2mg citalopram in the short-to-medium term (from there, we will begin a very slow micro-taper from the citalopram, but for now we are just struggling to stabilize). This is complicated by the fact that the citalopram has been pooping out since Mar 2023, which may also be contributing to the plateau in any improvement on the withdrawal symptoms.

• We're trying to use strategies other than drugs as much as we can. We are both taking medical leave. We're being strict about our bedtime routine, eating extremely healthy with tons of fruits and veggies daily and little-to-no processed foods, getting out for two walks outside daily, meditating 1-2 times daily, doing yoga at home, avoiding stressful or over-stimulating activities. We are visiting his family until things improve, for extra help with care and morale. These things are making a difference, but even with them we are in the current state.
• We don't want to increase the citalopram any more, (a) because he seems to have a severe kindling effect from any dose changes to citalopram and (b) because it's pooping out so updosing may not do much to help anyways, even in the short-term
• He would like to increase his fluoxetine dose to 20mg to help stabilize, provide some relief on the sooner side for the anxiety and depression, and hopefully continue to help with some symptom relief when he eventually tapers off of citalopram. We know that he's had a gentler reaction to fluoxetine starting & stopping in the past, which we feel makes it an okay strategy for him to use as an intermediate step. We're also hoping increasing the fluoxetine can allow us to eliminate the lorazepam sooner - although he isn't taking it daily, we know it is highly habit-forming and would like to remove it before anything else. But in his current state, it's the only thing that has been able to get him through his worst waves.

 

Our primary question-area for now (we'll probably have more later):

We're trying to figure out how to updose the fluoxetine, assuming that we do. What we're considering:

• All-at-once updose to 20mg
  • pros: 
    • get it over with; less time spent going through any updosing effects
    • after getting past updosing effects, will get to any relief it provides sooner
  • cons:
    • could be very destabilizing
• updose very slowly, basically a micro-increase
  • pros:
    • likely less destabilizing
    • if it ends up providing some therapeutic effect at a dose lower than 20, he could stop there at a lower dose
  • cons:
    • if there are still some negative effects to updosing, those would be drawn out over a long period of time
    • likely will take longer to get a therapeutic effect from the drug to get relief from the citalopram withdrawal/poop-out. in the meantime, his anxiety and depression is already severe and worsening day by day rather than improving
• middle ground?? target 20mg, but updose over a few weeks by 0.5mg/day or similar
  • pros:
    • maybe still less destabilizing than the all at once updose?
    • still get to some therapeutic effect sooner than the micro-increase version
  • cons:
    • could still end up being destabilizing, and then just prolong the destabilized period

 

Questions: 

• In your experience, does kindling tend to be specific per drug, or have you tended to find that when somebody develops a kindling reaction to one drug, they also begin to have kindling reactions to other psychiatric drugs including those that they haven't had severe reactions to in the past?
• We have read the reinstatement advice which says that increasing a dose after reinstatement should be extremely cautious and slow due to the likely kindling effect. But are there any general patterns or learnings around how best to increase dosage of a medicine in general, when not referring to a drug that you're already hypersensitive to?
• Any other advice on stabilizing for his particular situation?

[Emonda]

Welcome @olivepit

 

As a starting point, I suggest you put the medications being taken into the drug interaction checker: https://www.webmd.com/interaction-checker/default.htm. Looks like there may be a few things to be aware of / chat with a knowledgeable doctor about.

 

We are a very small team of volunteers, with a number of the team away at the moment. Please keep posts concise moving forward, as we have so much to read from so many people. 

 

On 1/15/2024 at 4:38 PM, olivepit said:

We're trying to figure out how to updose the fluoxetine, assuming that we do. What we're considering:

• All-at-once updose to 20mg

 

Our goal is to help those people who want to taper off ADs. Increasing from 10mg to 20mg of Fluoxetine is not something I can provide assistance with.

 

When people on this site do up-dose on their tapering journey, it is by very small amounts, less than 10%, followed by a period of time, maybe two or three weeks, to allow the body to adjust. However, if people notice an immediate unpleasant response to the up-dose, perhaps the up-dose was not a helpful step, and the decision needs to be reconsidered. 

 

On 1/15/2024 at 4:38 PM, olivepit said:

We know that he's had a gentler reaction to fluoxetine starting & stopping in the past, which we feel makes it an okay strategy for him to use as an intermediate step. 

 

does kindling tend to be specific per drug

 

Not that I am aware of: Kindling

 

Just because someone has been able to go on and off an AD in the past without problem, that does not mean that it will always be that way. I did this years ago, then eventually, experienced what I now understand was kindling.

 

On 1/15/2024 at 4:38 PM, olivepit said:

But are there any general patterns or learnings around how best to increase dosage of a medicine in general, when not referring to a drug that you're already hypersensitive to?

 

Slow, small changes are the way to go so you can monitor how the body reacts.

 

On 1/15/2024 at 4:38 PM, olivepit said:

Any other advice on stabilizing for his particular situation?

 

Windows and waves pattern of stabilization

 

Emotional Spirals

 

Non-drug coping strategies

 

Never taper by more than 10% per month: Why taper by 10% of my dosage?

 

If you experience unpleasant WD symptoms, that may be a sign you need to slow the taper down even more. 

Daily Checklist of Antidepressant Withdrawal Symptoms (PDF) 

 

We don't suggest many supplements, but two that many of us find helpful are magnesium and omega-3 fish oil. Here are the links for info about those. Add one at a time and start with a low dose to see how it affects you. 

Magnesium

Omega 3 Fish Oil

 

Avoid alcohol. 

 

Please post any updates here in your thread.

 

Once again, welcome to S.A.

 

Emonda.

[olivepit]

Updates: 

 

We made it cross-country to stay with family. Travel day was the worst yet symptom-wise, but symptoms significantly improved the first day here. Waves have been less severe and farther apart since then.

• We can only attribute the difference to family + a place he feels very safe + more sunshine, otherwise our routine is exactly the same. The therapeutic effect has been stronger than a benzo.
• Hasn't taken lorazepam since Jan 15 (5 days ago)
• Still observing if things continue to improve or if it plateaus. That will inform what we consider doing w/ fluoxetine in the short term.
• If we do updose fluoxetine it'd be to manage citalopram poop-out, since not all his WD symptoms are from tapering alone. Would be ideal if we could stabilize the poop-out before beginning to taper citalopram again.

 

 

@Emonda,

 

Thank you for the detailed reply. We've discussed interactions with a psychiatrist, PCP doc, and pharmacist so we feel prepared there. Thanks for the interactions checker link!

 

Quote

Please keep posts concise moving forward

 

Totally understand. I erred on the side of detail b/c instructions said the intro is used for future reference on somebody's full history. Should be easier to condense from here on, thanks for bearing with me.

 

On 1/19/2024 at 4:55 AM, Emonda said:

Our goal is to help those people who want to taper off ADs.

 

The updose of fluoxetine would be only as a tool on the way to tapering. Even though the short-term question is about updosing, if it may help with tapering in the long-term for this situation it still feels relevant as a question. Appreciate you doing your best to share knowledge even if there may be less info about updosing here.

 

Quote

Just because someone has been able to go on and off an AD in the past without problem, that does not mean that it will always be that way. I did this years ago, then eventually, experienced what I now understand was kindling.

 

Very helpful background. I think we will plan to be gradual with any fluoxetine changes, and not assume that it will be as smooth as it was in the past (both if we decide to updose, and later on when tapers off after he's done tapering citalopram)

 

OlivePit