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Altostrata

The Prozac switch or "bridging" with Prozac

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Lilu

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.

 

Prozac shown to affect Norepinephrine and Dopamine

 

CONCLUSION: Amongst the SSRIs examined, only fluoxetine acutely increases extracellular concentrations of norepinephrine and dopamine as well as serotonin in prefrontal cortex, suggesting that fluoxetine is an atypical SSRI. 

source: http://www.biopsychiatry.com/fluoxdopnor.htm

 

5 mg shown to be just as effective as 10 or 20 mg

 

source: http://forums.studentdoctor.net/showthread.php?t=795088

 

"The results of three dose-effect studies... [demonstrated that] a dose of 5 mg per day was as effective as any of the higher doses." N Engl J Med 1994; 331:1354-1361.

 

5 mg helped 54% with major depression; 20 mg helped 64%. Fewer adverse effects with the 5 mg dose. Conclusion: "No lower limit for an effective dose of this potent serotonin uptake inhibitor has been demonstrated in moderately depressed outpatients. Psychopharmacology Bulletin 1998:

 

In the 5 mg, 20 mg, and 40 mg fixed-dose study, there were no differences in effectiveness between the active treatment groups, all of which were superior to placebo. Side effect dropouts increased significantly with dosage....With endpoint analysis, numerically, 5 mg/day outperformed 40 mg/day which outperformed 20 mg/day...These data point to 5 mg/day as optimal, although there is no evidence that doses below 5 mg/day are not equally effective." 

Journal of Clinical Psychiatry, 1992

 

"We conclude that starting fluoxetine at doses lower than 20 mg is a useful strategy because of the substantial fraction of patients who cannot tolerate a 20-mg dose but appear to benefit from lower doses.... Patients often benefitted clinically from treatment at lower doses, and failure to tolerate 20 mg/day of fluoxetine should not be taken as evidence that the agent cannot be used efficaciously in these patients. 

Journal of Clinical Psychiatry, 1993

........................................................................................................................................

 

So, perhaps Prozac is the best switch option after all. Especially for those of us who have been taking SNRI's.  And perhaps going up to 20 mg is really unnecessary when switching or bridging.  

 

Having taken Prozac in the past, I don't remember it ever being stimulating, but it wasn't sedating until I started taking really high doses of it.  This wouldn't be the case if the N & D were only effective at higher doses. 

 

Ughh...I just don't know. I'm thinking of switching to Prozac from Lexapro, which is making me so tired and drowsy all the time.  But I'm scared, cause when I took Prozac, I gained a lot of weight very quickly. I was hungry all the time, and I had leg jerks, and then I started sleeping a lot, but that was on 90 mgs.

Edited by Petu
fixed text

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PorkPie

Afternoon!

 

I'm about to switch directly from Sertraline (100mg) to Prozac (20mg) and taper down from there, with the idea being to lessen withdrawal.  However, I've since seen online that the recommended dose of Prozac is equivalent to 50mg of Sertraline... surely I'd end up feeling the missing 50 as well as any potential start up symptoms?  It strikes me as rather counterproductive.  Would doubling the dose head off at least the withdrawal and allow me to continue on my merry way?

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Altostrata

I don't believe anyone can answer that precisely. What knowledgeable doctors do is explained in prior posts in this topic.Here's a guess from http://www.globalrph.com/antidepressants.htm 

Approximate equivalent dosages of antidepressants:Citalopram 20 mgEscitalopram 5-10 mgFluvoxamine 100 mgFluoxetine 20 mgParoxetine 20 mgSertraline 50-75 mgVenlafaxine 75 mg

 

It's safer to taper directly rather than switching drugs, because the switch can be rough and doesn't always work to eliminate withdrawal problems. Have you tried tapering sertraline? It comes in a liquid http://survivingantidepressants.org/index.php?/topic/1441-tips-for-tapering-off-zoloft-sertraline/

 

PorkPie, please update your topic at http://survivingantidepressants.org/index.php?/topic/4981-porkpie-intro/

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jotuna

OK, it has taken me all dang day to read through this topic and skim others. My question is: should I cross-taper directly from to fluoxetine from 50mg desvenlafaxine?

 

I am close to 70, in good health, active, my brain works pretty well and I have a supportive spouse and social network. I'm truly blessed, as we say around here. So after reading everything my concerns are 1) that withdrawal will get too complicated - like having to step from desvenlafaxine to venlafaxine to fluoxetine, and 2) that whichever route I take will be destabilizing for long periods.

 

My history is not too complicated: I took Strattera/atomoxetine for several years. The downside to the Strattera was nausea if I took it with or before a meal for the first few months. Trying to quit Strattera cold turkey was BAD within a week so my family doctor put me on 50mg Pristiq/desvenlafaxine about 2 years ago. Side effects have ranged from minor - tinnitus - to insomnia. I took Prozac/fluoxetine briefly about 15 years ago during menopause with no particular side effects and no withdrawal problems. I take no other mood-affecting drugs or prescriptions. I don't think a slow metabolizer but I am 'old'.

 

I understand that you aren't substitutes for an expert mental health experts but in this backwater we don't have any. I'm just looking for informed opinion.

 

Thanks to all who spend time curating this site - good job!

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Meimeiquest

Have you ruled out an Effexor bridge? I have no opinion, just asking because it is similar to Pristiq.

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Altostrata

Early posts in this topic describe cross-tapering, that is, overlapping Pristiq and Prozac dosages to ease the transition from one to the other. A cold switch without overlap is riskier.

 

Switching to Effexor is probably somewhat less risky than switching to Prozac, but you're right, then you have to get off Effexor. See http://survivingantidepressants.org/index.php?/topic/272-tips-for-tapering-off-effexor-and-effexor-xr-venlafaxine/

 

I would not make a plan to switch from Pristiq to Effexor to Prozac. Two switches ups the risk even more. Going on and off drugs is highly stressful to the nervous system. Switches should be minimized.

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jotuna

Thanks for your input Meimeiquest & Altostrata! Yes, I considered Effexor, but then the last bit of tapering looked dicey. Prozac looked better for its long half life and the fact that it is available by prescription in a liquid. That sounds easier than trusting myself to concoct a dose correctly/consistently.

 

So let me get this straight: I'm now taking 50mg Pristiq. I could ask my doc for a one week prescription of 10mg Prozac to take concurrently with the Pristiq, then a 20mg Prozac prescription to take concurrently, then continue to take 20mg of Prozac only for a month to see if I'm stable. After that I could taper by 10% a month (of each preceding dose) as tolerated - is that right? 

 

Altostrata, I remember somewhere you had a link to an authority - Dutch, I think - that explained how SSRIs worked on receptors at the cellular level. I'd like to review it again but can't find it. Could you point me to it?

 

Thank you again for all the support!

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Altostrata

In the Prozac switch topic, one doctor suggests overlapping with 10mg Prozac, not increasing it, and tapering from there. I would do that. I wouldn't count on tapering only one month on Prozac. I'd allow a couple of months. If you do this, I hope it works for you. Please let us know.

 

I don't know which topic you're looking for. Sounds like it's in the Journals forum. Please look there.

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jotuna

OK, finally got my doc to prescribe liquid Prozac and started bridging 21-Jan-14. No noticeable changes 5 days on. 

 

BTW, when googling to see what a brain zap is so I will know if/when it occurs I found this link on Psychforums:  http://pubmedcentralcanada.ca/pmcc/articles/PMC1246084/pdf/bmj33100824.pdf

 

Sounds bad but at least it will mean withdrawal is progressing - right?

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Altostrata

No, a brain zap means you are tapering too fast and your nervous system is complaining.

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jotuna

OK, got it; thanks Altostrata. Will finish the week with both Pristiq and Prozac, then Prozac only for 4 weeks. Fingers crossed and doing meditation!

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jaschembra

I've been on antidepressants for over 10 yrs.  2 years ago, I switched from Cymbalta 60 to Pristiq 50 and went up to 100mg shortly after.... I want to be 100% clean from these drugs.  I feel I am in a much better place in my life and should be able to deal with issues as they arise.  I never had bad depression and as I think back I wonder how/why I've been on these drugs for so long.    1 month ago, I went from 100mg to 50mg Pristiq.  That went pretty smoothly.  2 weeks later, the NP said to go, 1 day on, 1 day off...  Well, my 1st day off was okay, but the next day I was extremely ill.  I took my 50mg that morning, but it took until the next day to fully function at best.  Was sick on a Sun. and missed work Mon.  Now I've been on the 50mg every day for 2 more weeks.  The plan is to switch to 20 mg Prozac tonight.  (took Pristiq 50 this a.m. and will start the 20mg Prozac at night).  Stop the Pristiq and continue on 20 mg Prozac for 6 wks.  Then see my Dr. for the next weaning process... which from reading seems to be 10 mg, and then liquid.   This stuff is sure scary.  I would never have thought a drug would have such control and if I would have known about Pristiq when it was prescribed, I would never have gotten on it (It did work well, but if you miss just hours of the dose, you would feel ill, I didn't like that!)  Any insight would be appreciated.  I pray this goes well.

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Ignacio

Hi guys,

 

Ive been reading this post recently and I would appreciate if you could lend me some advice as I'm looking not exactly looking to switch to Prozac but I have a similar problem.

 

  • I've taken 20mg Prozac for 2 years.
  • 2 months ago I stopped Prozac and started Lexapro as my psych commanded it.
  • Recently after starting Lexapro (which I think made me feel bad) I decided to taper of AD's. * Alto told me to taper from 10 mg Prozac, but at the time I thought  it didn´t matter to be on one drug or another, after I found that I could have withdrawal symptoms from Prozac.
  • I was only 7 days on 10 mg of Lexapro, and then lowered to 3 mg up till now.
  • My current dose is 3 mg Lexapro.

Since I changed to Lexapro and started the taper Ive been feeling worse, and was thinking that maybe this was due to Prozac withdrawal, as really the dose Ive been on lexapro have been a stable 3 mg nearly the whole time.

 

The last two days Ive made the mistake to try to up my Lexapro dose this was two days ago, it made me feel really frustrated and angry for no reason, so I suppose this is not the answer and yesterday I tried to take 1.5mg of Prozac, took 3 mg because I measured the wrong cuantity and made me feel a bit disoriented, nervous and activated. Today I can feel struck by the changes and will not be making any more changes like this (I can only learn from doing things wrong).

 

I wanted to know If I can be right about being Prozac the causative of withdrawal and if I could do something to make it ease. Maybe switching to Prozac is too much but, I dont know...

 

 

I would appreciate any help, I can see youve helped many people, 

 

Thank you

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Altostrata

Ignacio, no one can answer that question with certainty.

 

You may be having problems because you went on and off drugs before and that stressed your nervous system. Prozac might not be any better than Lexapro in that case. Or, you might be having Prozac-specific withdrawal symptoms that Lexapro is making worse.

 

Adding the Prozac as you did might have confused your nervous system even more.

 

Very sorry, I don't think we can give you any definite answers.

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LexAnger

Thanks all for the great info and experience sharing!

 

 

Any thoughts about the equivalent dose between Lexapro and Prozac?

 

 

I never thought to switch to be very conservative not playing with psych drugs as I am super sensitive to tiny changes of Lexapro during the tapering in the past 1.5 year, but now I have to consider this option as lex is giving me horrible side effects, most severe pain all over every day from the minute I start taking the liquid of it (4mg now over sever hours as taking the whole thing same time throw me into panic attack and heart failure from the pain) and it last many hours until very late of the evening.

 

 

It was believed lex is much more powerful than other ssris, how much Prozac is equivalent to, say 10mg of lex? And for my case, 4mg lex, what would be a good switching Prozac dose?

 

 

Any comments/thoughts are much appreciated.

 

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Altostrata

LexAnger, the substitution dosages of Prozac are discussed in detail in the early posts of this topic.

 

Thank you for the reference to that paper. Yes, there can a danger of serotonin syndrome when overlapping antidepressants. This is also addressed above.

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LexAnger

Hi alto, thank you for responding! I read the entire post carefully and learned a great deal. There is info about equavelent dosage for other ssris but no for lexapro. My appointment with doctor shipko is on 9/3. I will see what comes out of that. Even the decision is to switch, I will wait until I'm relatively stable with lex.

 

I have another question, during the overlapping dosing of the crossover, how far away the two drugs should be taken on a day? I'm guessing it's not a good idea to take both at the same time.

 

Kindest regards,

Lex anger

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Altostrata

Of the methods described above, my personal preference is the one that uses a somewhat lower dosage of Prozac -- not an equivalent dosage -- to substitute for an SSRI such as Lexapro. This also lessens the danger of excessive stimulation during the overlap period. I trust the psychiatrist who came up with that.

 

You should be able to discuss this with Dr. Shipko.

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LexAnger

I like your thoughts Alto, thank you for the reminder And confirmation! I hope dr shipko agrees.

 

I'm thinking 5mg to start, or even lower using liquid. I can increase if bad withdrawal but its better than SS. My hope is to stablize at 5mg prozac and taper from there later on.

 

Should I decrease lex along with the pace of increase of Prozac or take both with a constant dose then just drop lex at week 2?

 

 

From this post, it seems one other important thing is NOT to exceed 2 weeks overlapping.

 

Kind regards,

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Altostrata

Lex, all I can do is point to those methods described by doctors who have done this successfully. Clearly there's no one right way to accomplish the switch.

 

My own intuition is that the cross-taper with an overlap of perhaps a week (that brings the Prozac up to steady state in the blood level) and then a quick step-down of the other drug over maybe a week is what I'd prefer.

 

But I can't tell if that will work well for you, or if it is what Dr. Shipko would do. Please confer with him to work this out.

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LexAnger

Hi Alto, my sincere appreciation for your taking time ESP. Over the holiday weekend and your great advice! They all make great sense. One week overlapping provides the best rational per Prozac hilt life (4-6).

 

With all your help, I feel I'm close to a logistic and strategic for the switch. I will update after the 9/2 appointment with dr shipko.

 

Intolerable tapering of lex with as little as 0.05 mg decrease from 4.3mg (jaw and head pain, brain nonfunctioning, panic attack, heart problems, overall disability)

Intolerable maintenance with lex round 4.25 mg with hours sever needling pain plus other systematic damage inc. Constant physical (pain, numbness, hearing, vision problems). mental (confusion, loss of memory, concentration, thinking). Psychological (anxiety, depression, depersonalization) just name a few.

Pain killer had severe interaction with lex, not using pain killer for the rest of life is impossible

Was put on lex originally for a headache not anxiety or depression

 

What to be proposed to the doctor:

Add Low dose of Prozac on top of current lex 4.25mg for one week

Increase Prozac (to 5mg ?) start of second week and decrease lex (by 2mg?)

Stop lex end of the second week

 

Taper Prozac once it's stable

 

Now only thing left is praying. This will be a life changing event and its very scary, but I am pushed to the dead corner so have to make a move.

 

Kind regards,

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Altostrata

I believe that it's best to be prepared before talking with a doctor. You've done this, Lex.

 

I cannot predict whether your plan will be comfortable for you or whether switching to Prozac will be a better way for you to exit SSRIs. Your plan seems reasonable. It has caution built in. I don't know if ramping up on the Prozac would be necessary, but your plan tests the waters first.

 

Listen to what Dr. Shipko has to say and be prepared to be flexible. If he seems to understand your situation, he may have suggestions that are better.

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clarabella79

Hi Everyone,

 

I'm just curious to find out what people think about how fast - or slow - the Prozac switch should be best done. I've managed to wean down from 20mg to 10mg of Paroxetine over the last 6 months (probably too fast - hence why I'm going to be holding at this dose for at least 4 weeks), with the long term aim of moving onto Fluoxetine (Prozac) via a process of cross-tapering. I then want to reduce the Fluoxetine. I've read (on here and on various other sites) that Prozac is stimulating so I'm thinking of introducing it very gently because I've spent years on a sedative antidepressant. Does it sound like an over cautious plan - as an initial step - to introduce 1mg Prozac when I drop to 9mg Paroxetine and hold for as long as it takes me to feel "ok"? I'm going to book a GP appointment soon so want to go in with a plan of action of sorts. I can't see there being a problem with obtaining Prozac liquid, but if there is, I'll make my own from ground up 10mg pills. Any thoughts at all would be greatly appreciated :)

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Sarasmiles

I'll be interested to read the answers you get to your question, Clarabella.  

 

I'm trying to figure things out myself. I would really appreciate any feedback I could get.

 

On February 6, 2015, I told my psychiatrist I wanted to get off of Lexapro.  He recommended a switch to Prozac, because it has worked well for me in the past, and because I found it less difficult to withdraw from than Lexapro, which I tried to discontinue about a year ago, without success.   My true desire when I told him I wanted to get off of Lexapro was to be medication free at last.  I told him this, but he was skeptical that this would work for me.  He has seen me discontinue and suffer from bad depression in the past, and he seems to feel I will need to be on an SSRI for the foreseeable future.  So I agreed to the switch to Prozac, but told him, "if I do okay, I'd still like to taper off the Prozac eventually."  I was viewing the Prozac as a bridge drug, but he was viewing it as a replacement, albeit a replacement I could hope to get off of somewhat more easily should I insist upon that.

 

Okay, so he prescribed:

 

10 mg. Prozac for one week, while still taking 20 mg. Lexapro.  

10 mg. Lexapro for one week, increase to 20 mg. Prozac

5 mg. Lexapro for one week, 20 mg. Prozac

Quit Lexapro, stay on 20 mg. Prozac

 

After spending hours reading here, I decided not to increase the Prozac to 20 mg., but instead to see if I could be stable reducing the Lexapro while taking 10 mg. Prozac.  I did that.  So I have been off of Lexapro entirely since 2/28. I had some dizziness and a few brain zaps each day after beginning the Lexapro reduction, but basically felt pretty good. I continued to take  10 mg. of Prozac until 3/3, when I shaved a tiny bit off of my 10 mg. tablet. Since then I have continued to do that, taking 9 mg. of Prozac each day, until 3/10, when I reduced that to 5 mg.  I thought, based on past experience, that I could probably handle that reduction.

 

That brings us to yesterday, when I had my first emotional sign of withdrawal. I became unreasonably enraged with my husband. There is a lot of anger built up for me in that relationship, so it was not coming from out of nowhere, but it was definitely out of proportion to the immediate situation, and I felt almost dizzy with anger.  It was that hot, visceral, sickening rage I have only felt a few times in my life. And it was over a minor issue. I stayed in control of my behavior and my words, and he doesn't know just how angry I was. 

 

Today I woke up with a massive headache, and felt hung over, although I haven't had a drink in months.  Fortunately, I had the day off, and I was able to spend some of it in bed.  I feel better now.

 

Would anyone be willing to advise me about how I should proceed from here?  I could hold at the 5 mg. of Prozac and see how I do in the days to come.  I could go back up to 9 or 10 mg.. I could taper by smaller amounts, which would require me to use a liquid form.  My pharmacy wouldn't do a refill as a liquid unless I get a new prescription written that way.  I'm uncomfortable asking my psychiatrist to do that, given his disapproval of my going drug free at all, but I could do it, or make my own.

 

This afternoon I feel fine.  I needed the rest I got today, but I am good now. Just mildly dizzy.  Of course, I don't know if the headache and rage were reactions to Lexapro withdrawal from 2 1/2 weeks ago, or Prozac reduction.  

Any advice would be appreciated enormously.

Thank you!

Sara

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blackrabbit

Hi everyone. This thread is huge so I haven't looked through every page. Just the first three. To save me some time, has *any*one done the prozac bridge with Lexapro? My doctor approved me doing it so I am going to start soon. I am just nervous. 

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Altostrata

Of course. It's done frequently. You might search this thread for Lexapro if anyone's mentioned it here.

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grandmaD

I have copied this statement from post no. 7 by Alto:

 

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.

 

My question is in regard to the 3rd bullet.  Is this saying that if I ALREADY have severe w/d symptoms from the paxil, that a switch to, say prozac, will not cure those symptoms?  Is that right?

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scallywag

grandmaD -- you are interpreting that statement correctly.

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grandmaD

Okay, thanks Scallywag.  Bit of a let down there!  I was hoping the crossover/bridge to Prozac would help w/d symptoms!  I have finished reading this thread now, and my opinion now, is that it is best to do it when you are stable (sufficiently I gather, but not entirely) on current a/d.  Then the only reason to switch would be that it is easier to get off Prozac.  It seems there might be more success stories than failures, at least.

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frederike01

Hi there!

 

i switched to prozac 6 months ago. I was on Paxil 14 mg. And i just couldn't  taper off any further. Even 0,2 mg gave me sooo much withdrawal symptoms. So i decided to switch to prozac. I have a pill i can turn into liquit myself. There was no suspension available. Wich i did have for paxil.

I switched from 14mg paxil to 15mg prozac. It was a very difficult decision to make and i've doubted for a very long time to. At first i thought i wanted to witch slowly, but docters recomended to switch all at once, because the meds. are so simular they said. I was allready experiencing a lot of wd symptoms because of tapering off paxil. And whatever i did i would experience them anyway so in the end i listened to the docters and i took the risk to switch all at once. Switching caused me a lot of extra wd symptoms again for like 3 weeks. then i started tapering off again. The docters told me i could stop all at once again because of the long half life time. ( is that the right word btw? haha) I knew that would be wayyy to fast for me but i still had a little hope this meds would be easier to get off than paxil so i decided to taper off 2 mg. a week. i was allready experiencing a lot off wd symptoms from tapering off paxil and switching to prozac but after that first week i really felt no extra wd at all. so the next week i tapered off 2 mg again. Stil my wd symptoms didnt worsened.so i kept doing the same thing untill i was on 4 mg. I was scared the whole time that my wd reaction would still come, but docters told me it would be ok. Somewhere i knew better but  at the same time i hoped i was wrong. Well it turned out i wasnt wrong again :(. When i was on 4 mg the very very bad wd symptoms still appeared. And they're with me ever since.

 

Still i think it was a good decision to switch to prozac. I tapered off way to fast again, but im sure i would have never gotten this far by staying on paxil.

If you reduce slowely i think switching to prozac is a goot thing to do. But only if it's impossible to taper off the meds. your on. Because the switch itself isnt easy either. I switched at once of cource. But i think switching is always a risk... I hope my story might be helpfull. :)

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Altostrata

Thanks, fredericke. We would advise against tapering while you are experiencing withdrawal symptoms. After a switch, we urge people to allow their nervous systems to stabilize on Prozac for some months before reducing it.

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frederike01

Yes altostrata you are right and if i could make that decision again i would definitely do that. :(

My psychiatrist told me i could start tapering.

Foolisch of me to believe that of cource.

On the other hand though, i never was stabel before, because of my earlier fast tapering off fluvoxamine an paroxetine.

And the reason i started tapering off fluvoxamine was because i already was experiencing "poop out" (i think because my symptoms worsened more then they had ever been)  after using the meds 12 years.

Wich i did not know back then by the way....So i think i never could have done it without being unstable. That's what makes it so difficult......:(

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Altostrata

Please post questions about your particular situation in your Intro topic.

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InvisibleUnless

im sorry if i am overlooking information posted in other areas, but i was wondering if there are any studies supporting the decision to cold swap between SSRIs rather than tapering or cross-tapering.

 

a lot of psychiatrists seem to think SSRIs, in particular, are okay to switch between without a taper--and not just drugs being exchanged with active metabolites ala citalopram/escitalopram or fluoxetine/norfluoxetine.  is this backed by evidence or is this just massive assumption paired with 'discerning clinical judgement' from 'years of experience with hundreds of patients'?

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