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The Prozac switch or "bridging" with Prozac

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Altostrata

Note from site administrator:

Read this entire topic before attempting a switch to Prozac. Be sure to read details and cautions below . Consult a knowledgeable medical practitioner before changing medications.

 

Also see Tips for tapering off Prozac (fluoxetine)


Switching or bridging with another drug, usually of a longer half-life, is a recognized way to get off antidepressants, particularly those that people find difficult to taper.
 
Many people with failed tapers from venlafaxine (Effexor), desvenlafaxine (Pristiq), paroxetine (Paxil), and duloxetine (Cymbalta) find they need to bridge in order to go off the drug. For many doctors, a switch to Prozac to go off a different antidepressant is routine.
 
Fluoxetine (Prozac) has the longest half-life of any of the modern antidepressants. Because it takes about a week for a dose to be metabolized completely, if a switch to fluoxetine is successful -- that is, does not cause withdrawal symptoms from the original drug -- a careful taper off fluoxetine is easier for most people -- see information about Tapering off Prozac. And, at least fluoxetine comes in a liquid.
 
(Citalopram or Celexa and its sibling escilatopram or Lexapro have half-lives of about 35 hours, a relatively long half-life among SSRIs, and are other candidates for a bridging strategy. They also come in a liquid form. The drawbacks and advantages of switching to another drug to get off the first drug, described below, apply to a switch to citalopram or escilatopram as well as fluoxetine.)
 
While going off fluoxetine usually has less risk, one might still develop withdrawal symptoms going off fluoxetine. No bridging strategy is risk-free.
 
You must find a knowledgeable doctor to help you to with a bridging strategy. You might wish to print this post out to discuss it with your doctor.
 
When to switch or bridge
A direct taper from the drug to which your nervous system is accustomed carries less risk than a switch to a new drug. You may have a bad reaction to a new drug, or the substitution may not work to forestall withdrawal symptoms. This is the "the devil you know is better than the devil you don't know" rule.
 
The risk of a switch is justified if you find a  taper from the original drug is simply too difficult. Usually people will do a switch when they find reducing the original antidepressant by even a small amount -- 10% or even 5% -- causes intolerable withdrawal symptoms. (I have heard doctors say they don't even try tapering off Effexor and Paxil, they do the Prozac switch from the beginning.)

 

Sometimes when people go down to a low dose of an antidepressant (such as paroxetine), they find further reduction is very difficult. Substituting a longer-acting SSRI such as fluoxetine may be worth the risk.

If you're thinking of switching simply as a matter of convenience, you need to weigh the risks against the amount of convenience you would gain. Generally, switching for convenience is a bad idea.

Risks of bridging
For most people the switch goes smoothly but for some it doesn't. A bridging strategy has the following drawbacks for a minority of those who try it:

  • Adverse reaction to the bridge drug, such as Prozac.
  • Dropping the first antidepressant in the switch causes withdrawal symptoms even though you're taking a bridge drug.
  • If withdrawal symptoms are already underway, switching to a bridge drug doesn't help
  • Difficulty tapering off the bridge drug. All of the bridge drugs can be difficult to taper themselves.

So, like anything else, the Prozac switch is not guaranteed to work. But if you are having intolerable withdrawal from another antidepressant, it may be worth risking the worst case in the Prozac switch: It doesn't help and you have withdrawal syndrome anyway.

 

CAUTION: A switch to a bridge drug is not guaranteed to work. It's safer to slow down a taper than count on a switch. A switch really should be used only when a taper becomes unbearable or there are other serious adverse effects from the medication. You must work with a doctor who is familiar with bridging, in case you develop severe symptoms.

Below is information I've gathered from doctors about exactly how to do the Prozac switch.

Healy 2009 method for the Prozac switch
From Healy 2009 Halting SSRIs withdrawal guidelines:
 

 

Quote
  • 1A Convert the dose of SSRI you are on to an equivalent dose of Prozac liquid. Seroxat/Paxil 20mg, Effexor 75mg, Cipramil/Celexa 20mgs, Lustral/Zoloft 50mgs are equivalent to 20mg of Prozac liquid. Or 40 mg of Paxil/Seroxat to 40 mg Prozac. The rationale for this is that Prozac has a very long half-life, which helps to minimise withdrawal problems. The liquid form permits the dose to be reduced more slowly than can be done with pills.
  • Some people may become agitated on switching from Paxil/Seroxat to fluoxetine in which cases one option is take a short course of diazepam until this settles down. Whether this agitation is caused by fluoxetine or because for some people the substitution simply cannot be made may be difficult to determine. If the agitation gets better when the dose of fluoxetine is reduced then its more likely to be caused by fluoxetine, if it gets worse, then it is more likely to be linked to withdrawal.
  • 1B A further option is to convert to a liquid form of whatever drug you are on. Many people cannot change easily from paroxetine tablets to fluoxetine and switching to paroxetine liquid may do the trick instead.
  • 1C Yet another option is to change from paroxetine to a mixture of half the previous dose in the form of paroxetine and the other half in the form of fluoxetine, and then to reduce the dose of paroxetine gradually.

 
Phelps-Kelly 2010 method for Prozac switch
From Clinicians share information about slow tapering (2010)
 

Quote

For any anti-depressant you can add in 20 mg of Prozac, get them off the anti-depressant, then taper the Prozac.

 
Jim Phelps, one of the authors of the above, posted in 2005 in some detail about the so-called "Prozac bridging" strategy. He said it is described in Joseph Glenmullen's book, Prozac Backlash, maybe in the chapter titled of "Held Hostage."
 
The technique Dr. Phelps described in this post skips doses and finishes with alternating dosages, which we do not recommend for people who are sensitive to withdrawal symptoms. Given that Prozac liquid is available, this is completely unnecessary.
 
Foster 2012 method for Prozac switch
Dr. Mark Foster, a GP whose mission is to get people safely off psychiatric drugs includes this in a presentation he gives to doctors. http://www.gobhi.org/spring_conference_powerpoints/safewithdrawal_of_psychotropics%5Bautosaved%5D.ppt.
 

Quote

Special Situations: The Prozac Switch

  • For patients that have a hard time withdrawing from other SSRIs (such as Effexor or Paxil), switching to Prozac can be effective bridging.
  • Prozac has the longest half-life and therefore the most gradual withdrawal effects.
  • Start the patient on a low dose of Prozac when severe withdrawal symptoms occur.
  • Wait two to four weeks, and then resume the prior tapering schedule.
  • Once the first SSRI has been stopped, then taper the low dose of Prozac over another 4-8 weeks.

 

 
His method involves overlapping Prozac with the other antidepressant.
 
Note on above: If you have tapered to a lower dose of Seroxat/Paxil, Effexor, Cipramil/Celexa, Lustral/Zoloft, etc., an even lower dose of Prozac may be more tolerable. If you are about half-way down, you might want to try 10mg Prozac. If you have decreased further, you may wish to try 5mg Prozac. More is not better for nervous systems sensitized by withdrawal.
 
Prey 2012 method for Prozac switch
Another knowledgeable doctor (whom I trust) explained his technique to me (this is the technique I personally would prefer if I had to do it, it seems much gentler😞

  • For a "normal" dose of Effexor (150mg per day or more) or Paxil (20mg) or Cymbalta (20mg), he would switch to 10mg Prozac with a week of overlap. In other words, take both medications for a week and then drop the Effexor. Lower doses of Effexor or other antidepressant require lower doses of Prozac as a "bridge."
  • The lower dose of Prozac reduces the risk of excessive serotonergic stimulation (serotonin toxicity) from the combination of the two antidepressants during the overlap period.
  • Do not stay on the combination of the first antidepressant and Prozac for more than 2 weeks, or you run the risk of your nervous system accommodating to the combination and having difficulty tapering off both antidepressants.
  • Later, taper off Prozac. He acknowledged Prozac can have its withdrawal problems, but given Prozac's long half-life, gradual tapering should be much easier than tapering off Effexor.

WARNING Serotonergic effects of an SSRI such as Prozac, Celexa, or Lexapro are ADDED when you are taking an SNRI such as desvenlafaxine (Pristiq), duloxetine (Cymbalta), venlafaxine (Effexor), venlafaxine XR (Effexor XR), milnacipran (Savella), and levomilnacipran (Fetzima). You run the risk of serotonergic toxicity if you are taking an SNRI, particularly at a high dose, with an SSRI. This is why doctors familiar with the Prozac switch will add in a LOW DOSE of Prozac to an SNRI.

 

In addition, escilatopram (Lexapro) is several times stronger, milligram for milligram, than the other SSRIs. If you add 10mg Lexapro to, for example, the high dose of 60mg Cymbalta, you will run the risk of serotonergic toxicity -- 10mg Lexapro is equal to approximately 30mg Prozac.

 

What should the final prozac dose be?

Please note that if you cross-taper, you will be taking 2 drugs at once for part of the time. Because of the potential of serotonin toxicity by overdosing SSRIs as well as SNRIs, it's probably safest to err on the lower side of a Prozac dose "equivalent" to your original drug.

 

For an idea of equivalent doses of your medication to fluoxetine (prozac) read this post (January 7, 2018) in this topic.  It compares fluoxetine 40mg/day (a fairly high dose of Prozac) to other antidepressants. Source of that data: https://www.ncbi.nlm.nih.gov/pubmed/25911132

 

Also see

 

Edited by Altostrata
updated

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InNeedOfHope

One thing I just can't work out is this. In the cases of SRNI's it is working on two systems. How does Prozac, cover the effects of withdrawal and brain function that needs to heal? It may cover the pain, but how does it pick up and replace the actual function of noradrenaline? I would be so scared because noradrenaline is involved in the heart beating and other bodily functions. Any ideas? Of course it is tempting, but if it goes wrong it could go wrong horribly.

 

The charity who helps me contacted David Healy and he would only suggest liquid Cymbalta. I wonder why he did not recommend Prozac for me? He had all the details of what had happened to me but did not suggest it, I wonder why?

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Altostrata

Only David Healy could answer that, InNeed.

 

As for how Prozac manages substitution even for SNRIs, nobody knows how that works. Perhaps the actual mechanisms of these drugs are not completely understood.

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strawberry17

Is it possible for the charity helping you to contact David Healey again and ask those questions for you?? Have you thought about liquid Cymbalta?

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Altostrata

Cymbalta does not come in liquid form. I just got off the phone with Lilly. The pellets have a timed-release coating on them. They cannot be dissolved.

 

I don't know what Dr. Healy was thinking. Something must have gotten lost in translation.

 

Info about Cymbalta tapering http://survivingantidepressants.org/index.php?/topic/283-tips-for-tapering-off-cymbalta-duloxetine/page__p__3034__hl__cymbalta__fromsearch__1#entry3034

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InNeedOfHope

I thought that, but I spoke to a chemist in Wales I think it is called Rosemount(they were in one of Dr Healy's protocol guides, an old one I think) and was told it can be done, but it costs a huge amount. Can't remember how much, around £400 for a months supply. I wonder if they are mistaken, they must be, if Lily themselves say no. It is strange because I wrote to him in February and he suggested imipramine, which my psychiatrist said no way to. The charity wanted to check out if he had any more ideas as things move on all the time, hence why they wrote again. They were worried I lack an enzyme that breaks it down and wanted his input and that is when he suggested liquid Cymbalta saying it was expensive but I should insist upon it. He must have made a mistake.

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Altostrata

There's no way to tell where the miscommunication was.

 

The enzyme question involves liver enzymes. If you lack or are weak in a liver enzyme, you are a "poor metabolizer" and may have adverse reactions when you take even a low dose of a drug.

 

I can't see how CITA or Dr. Healy could have supposed you are a poor metabolizer because Cymbalta is metabolized by 2 liver enzymes, not one. It's unlikely you are a poor metabolizer in both enzymes.

 

At any rate, the liquid Cymbalta suggestion is not actionable.

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strawberry17

Can I just say, I know a lady who tried to taper off tablets and had terrible results because she used a jewellry scale, but it was really hard to get a consistent reading and she struggled dreadfully. The tablets will be ok to stabilize on for a month or so but when it comes to the taper, you would be much better off with liquid Prozac and a 5ml syringe to get an accurate measurement. For example I was able to go from 5ml to 4.90ml for my first reduction.

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Shanti

Thank you InNeed :)

 

Strawberry, I was just looking at your Prozac timeline. So you've been tapering since 2008? Wow, that's a long time. But, if I have to do that I will. I just want to get far far away from this Paxil and I feel like Prozac will really help. I'm glad you kept a blog.

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summer

I can't exactly remember my Prozac taper... but, Prozac definitely helped me taper off Paxil. I think I started Prozac (20mg) when I had tapered down to around 5mgs of Paxil. At that point I went off the Paxil, and that worked really well for me. Once I was ready, I tapered the Prozac (cutting the pills) with little or no problems. Really can't remember any.

 

I eventually started taking Celexa, but that's a whole other story.

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Shanti

Thanks Summer. I'm glad to hear that.

 

Does anyone know why a longer half-life makes withdrawals easier? It seems to me it would just delay the withdrawal symptoms.

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Altostrata

A longer half-life means it's leaving your body slower, giving your nervous system more time to adapt to the change.

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compsports

Thanks Summer. I'm glad to hear that.

 

Does anyone know why a longer half-life makes withdrawals easier? It seems to me it would just delay the withdrawal symptoms.

 

Good question.

 

I have read that with most ADs, you should wait a minimum of 3 weeks before making the next cut. With Prozac, you might want to wait a minimum of 4 weeks.

 

Personally, I experienced hell with Prozac cold turkeys which supposedly doesn't happen due its long half life. Another story.

 

In spite of these questions and concerns, if I was having the experience from hell in tapering off of my current AD and there was no hope for improvement, I would take the risk and cross taper to Prozac.

 

CS

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Altostrata

Strawberry, how exactly did you do the switch? I mean go off the Lustral after you started liquid Prozac.

 

Here's the thing:

 

Nobody knows exactly how the Prozac makes up for the disappearance of the other drug. It's just known to work sometimes.

 

As I understand it, you go off the first drug fairly soon after starting the Prozac. I'm thinking that's while your brain is still "lifted up" by the new drug.

 

My worry is that if you wait too long, you lose the element of surprise. Your brain accommodates to the combination of your first antidepressant and Prozac, and then you still have problems withdrawing from the first drug.

 

Some doctors call this a "cross-taper" and as far as I know, it's done in a short amount of time.

 

I won't be able to confirm this for 10 days, when I talk to a doctor who knows this method very well.

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Shanti

Strawberry, how exactly did you do the switch? I mean go off the Lustral after you started liquid Prozac.

 

Here's the thing:

 

Nobody knows exactly how the Prozac makes up for the disappearance of the other drug. It's just known to work sometimes.

 

As I understand it, you go off the first drug fairly soon after starting the Prozac. I'm thinking that's while your brain is still "lifted up" by the new drug.

 

My worry is that if you wait too long, you lose the element of surprise. Your brain accommodates to the combination of your first antidepressant and Prozac, and then you still have problems withdrawing from the first drug.

 

Some doctors call this a "cross-taper" and as far as I know, it's done in a short amount of time.

 

I won't be able to confirm this for 10 days, when I talk to a doctor who knows this method very well.

 

I didn't think of that. I planned on taking my time. I'm glad you said something. Do you think this applies to the amount of time you spend on titrating up?

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strawberry17

I didn't do any cross taper, I just switched from Lustral one day to equivalent dose Prozac the next day and miraculously that worked, strangely I was always able to switch from one SSRI to another no problem, just couldn't get off the bloody things!

I don't know if this would work for everyone though, sorry that wasn't much help?

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Altostrata

Yes, I think the switch is like changing a tire: you jack up the car, then pull the tire out.

 

Or I hope this is the case!!!! As I said, I won't be able to ask a knowledgeable doctor for a week. But that will be enough time to get back to you, Shanti.

 

I know that after suffering horrible withdrawal symptoms, it can be scary thinking about just dropping the offending drug.

 

As we discussed, Shanti, you might consider coming off Paxil in 4 steps, but rather quickly. In consultation with your doctor, of course.

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Baxter

One thing I just can't work out is this. In the cases of SRNI's it is working on two systems. How does Prozac, cover the effects of withdrawal and brain function that needs to heal? It may cover the pain, but how does it pick up and replace the actual function of noradrenaline? I would be so scared because noradrenaline is involved in the heart beating and other bodily functions. Any ideas? Of course it is tempting, but if it goes wrong it could go wrong horribly.

 

The charity who helps me contacted David Healy and he would only suggest liquid Cymbalta. I wonder why he did not recommend Prozac for me? He had all the details of what had happened to me but did not suggest it, I wonder why?

 

 

T I am disappointed that Healey isn't aware of that there is no liquid Cymbalta, and because it is extended release, compounding pharmacists cannot work with it by grinding it.

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InNeedOfHope

I know that Altostrata on here said it can't be done, the charity rang Eli Lily to check today as they usually follow David Healys advice. As I expected, no, it can't be done.

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Altostrata

I phoned Lilly myself some time back, asked about liquid Cymbalta, and posted what I found on this site in several places. No, there is no liquid Cymbalta.

 

Either Dr. Healy erred, CITA misunderstood him, or CITA misspoke and said InNeed was on citalopram instead of Cymbalta.

 

It's quite easy to phone any pharmaceutical company to get details like this, and I urge everyone on this site to do this if they have any questions about the forms a medication comes in.

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Altostrata

Yes, I think the switch is like changing a tire: you jack up the car, then pull the tire out.

 

Or I hope this is the case!!!! As I said, I won't be able to ask a knowledgeable doctor for a week. But that will be enough time to get back to you, Shanti.

 

I know that after suffering horrible withdrawal symptoms, it can be scary thinking about just dropping the offending drug.

 

....In consultation with your doctor, of course.

 

I checked with a knowledgeable doctor and he confirmed the "changing tires" metaphor. To do the Prozac switch, you quit the offending drug (Paxil, Effexor, Pristiq, Cymbalta, etc.) fairly soon after starting Prozac -- within 2 weeks.

 

Any longer than 2 weeks, you run the risk of your nervous system accommodating to the combination of the two antidepressant. He said if this happens, you lose the advantage of the Prozac boost and you could have difficulty tapering off both of them. He also was concerned about excessive serotonergic stimulation from taking two antidepressants together.

 

He said he's seen it frequently that people manage to taper about half-way off Paxil, Effexor, Pristiq, Cymbalta, etc. and get stuck, any further reductions in dosage causing unacceptable withdrawal symptoms. That's when he does the Prozac switch, with a half-dose (10mg) of Prozac.

 

Please be aware the Prozac switch has these drawbacks for a minority of those who try it:

  • Adverse reaction to Prozac
  • Switch causes withdrawal symptoms on its own
  • If withdrawal symptoms are already underway, switching to Prozac doesn't help
  • Difficulty tapering off Prozac

More information at http://survivingantidepressants.org/index.php?/topic/1463-the-prozac-switch-or-bridging-with-prozac/page__view__findpost__p__13616

 

Please consider this in consultation with your doctor, of course.

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Shanti

I thought it would be a good time for an update on my Prozac switch.

 

The switch was easy and without incident at all. I was doing great until I went from 20 mg Prozac to 16 mg. It was too big a drop. I didn't have severe symptoms though. Only some zaps upon sleep. I updosed to 18 mg Prozac and am fine now. I have to taper a bit more slowly off the Prozac than I thought I would. I didn't have any mood changes, no depression or anxiety.

 

One thing that bothers me is that I have had tinnitus but it started just before the Prozac switch. This hasn't gone away. I pray it isn't permanent.

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Altostrata

That is such good news, Shanti.

 

You might want to stabilize on Prozac for a bit, then think in terms of decreasing it 1mg at a time, or less if you get any withdrawal symptoms at all. Remember, your system has gone through a lot of stress!

 

The tinnitus may be a legacy of the Paxil withdrawal symptoms. All the more reason to go very slowly with any more changes in your nervous system balance.

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strawberry17

I am seconding Alostrata's comment, it would be best to stabilize on the Prozac first, in my experience there really is no such thing as too slow, even with Prozac. Trying to work out the maths as over here in the UK I measure it from a starting dose of 5ml. I think 20mg to 18mg. you've dropped by 1/10th, which is still a biggish drop (well for me it would be).

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Shanti

Okay. I'm taking both your advice. I wanted to hurry off of Prozac. But yeah, I need to let my CNS rest. I'll stay on 20 mg a little longer then go slow drops. At least I'm far away from that horrid Paxil. I feel like I'm on the lesser of two evils now. Or the evil of two lessers lol.

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Shanti

My tinnitus is gone! Thank God! I haven't had it for 2 days now. I'm sure it was left over from the Paxil now.

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Shanti

Now if Only I can get her to switch me from Xanax to Valium. I'll find out tomorrow. That's another story unrelated to ad.

 

I wanted to post an update on my Prozac switch. I am so grateful to have learned of this option here! It has been hundreds of times easier to taper off the Prozac than it was trying to taper even by 1 mg below 20 mg of Paxil. I have motivation and feel hope for my future. I'm not done yet, but I'm very close and I feel good :)

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electron

Hello everyone,

 

I'm new to the forum but wanted to let you know that I successfully switched to Prozac from Sertraline. I was taking 100 mg Sertraline to begin with, then down to 50 mg each day, then 25 mg. I then explained to my doctor what I wanted to do and then managed a straight switch to 20 mg Prozac with no overlap. I had no withdrawal symptoms from the Sertraline. I put the success of this switch down to tapering off the first drug as much as possible to begin with and then switching to an equivalent dose of Prozac with no overlap between the two drugs. I think 20 mg Prozac is roughly equal to 10 mg Sertraline. I then stabilised on the Prozac and am now on my second withdrawal attempt from that. I hope this is helpful!

 

electron

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jr1985

RE; The Prozac Bridge, would a safer method be to take 5mg with your current dose for a week. Then increasing to 10mg for the second week and decreasing your current AD to half current dose. Then just drop the current AD completely, after the second week?

 

So..

 

Week 1: 5mg Prozac + 37.5mg Effexor (for example)

Week 2: 10mg Prozac + 18.75mg Effexor

Week 3: 10mg Prozac

 

The smaller starting dose would allow you to assess how Prozac affects you before going up to the full dose, plus the smaller dose of Prozac during the first week, and smaller dose of current AD in second week, could prevent any complications from too much serotonin (serotonin syndrome, etc).

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Altostrata

jr, I moved your post here, with the accumulated wisdom about the Prozac switch.

 

That method is called cross-tapering and it's the way I've heard some doctors describe they do it.

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jr1985

Those of you who made the switch to Prozac - were you still having w/d symptoms on your previous AD before you switched, or did you wait until you were completely stable before switching?

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Shanti

I was somewhat stable at 20 mg of Paxil before I did the switch. I got stuck at 20 mg Paxil during my Paxil taper. Every time I tried to go below 20 I'd get bad symptoms. So, yes, I'd say I got pretty stable at 20 mg before switching. I wasn't totally stable, as I was still healing from the taper from 40 to 20. But only mildish symptoms like tinnitus and feeling out of whack. But not brain zaps and harsh symptoms. I'm trying to recall how I felt but it's blurry :(

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strawberry17

Yes I think I made sure I was stable before I switched.

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dalsaan

Has anyone switched from Mirtazapine (remeron) to Prozac? Or from an AD that was in a different class to Prozac. Am thinking about this but am nervous

that I will still have withdrawal effects due to the different mechanisms of action between Mirtazapine and Prozac.

 

dalsaan

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jr1985

Switching from Effexor to mirtazapine didn't work for me. I had withdrawals which appeared as moments of rage and suicidal thoughts. It was very bad. I was able to switch between other antidepressants, but they were all ss/snri's. So I suspect the mechanism does make a difference. I wouldn't risk it.

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