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Horowitz, 2019 Tapering of SSRI treatment to mitigate withdrawal symptoms


Henosis

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Published:March 05, 2019 The Lancet DOI:https://doi.org/10.1016/S2215-0366(19)30032-X

Tapering of SSRI treatment to mitigate withdrawal symptoms

Mark Abie Horowitz, PhD

Prof David Taylor, PhD

 

Summary at https://www.thelancet.com/journals/lanpsy/article/PIIS2215-0366(19)30032-X/fulltext Full text here.

 

All classes of drug that are prescribed to treat depression are associated with withdrawal syndromes. SSRI withdrawal syndrome occurs often and can be severe, and might compel patients to recommence their medication. Although the withdrawal syndrome can be differentiated from recurrence of the underlying disorder, it might also be mistaken for recurrence, leading to long-term unnecessary medication. Guidelines recommend short tapers, of between 2 weeks and 4 weeks, down to therapeutic minimum doses, or half-minimum doses, before complete cessation. Studies have shown that these tapers show minimal benefits over abrupt discontinuation, and are often not tolerated by patients. Tapers over a period of months and down to doses much lower than minimum therapeutic doses have shown greater success in reducing withdrawal symptoms. Other types of medication associated with withdrawal, such as benzodiazepenes, are tapered to reduce their biological effect at receptors by fixed amounts to minimise withdrawal symptoms. These dose reductions are done with exponential tapering programmes that reach very small doses. This method could have relevance for tapering of SSRIs. We examined the PET imaging data of serotonin transporter occupancy by SSRIs and found that hyperbolically reducing doses of SSRIs reduces their effect on serotonin transporter inhibition in a linear manner. We therefore suggest that SSRIs should be tapered hyperbolically and slowly to doses much lower than those of therapeutic minimums, in line with tapering regimens for other medications associated with withdrawal symptoms. Withdrawal symptoms will then be minimised.

Edited by Altostrata
added link

Medication before problems: Took Paxil 60-100mg from 2003 to 2014 for OCD.
1) Last pill taken November 2014, horrendous withdrawal started six weeks later.

2) Re-instated successfully @ 20mg May 2015, but accompanied by severe anhedonia, loss of emotion, apathy, and fatigue

3) Switched to Prozac, Viibyrd, Zoloft, Nefazadone, Cymbalta, Nardil in attempt at abating WD symptoms while not re-introducing anhedonia. Each one either failed to relieve WD or brought back anhedonia. So re-stabilized on Paxil at 15mg

4) Tapered down to 7.5mg as of October 2016. More energy, anhedonia/loss of emotions remains apart from short windows.

5) May 2017 - down to 3.5mg of Paxil (no other meds)
6) Early 2018 - added 8mg of Prozac
7) January 2019 - down to 1.05 Paxil / 5mg Prozac and continuing

8) October 2019 - down to 0.2mg Paxil / 3mg Prozac

9) November 2019 - down to 0.1mg Paxil / 3mg Prozac 

10) March 2020 - done with Paxil, 2.5mg Prozac

11) April 2021 - 0.03mg Prozac

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“We examined the PET imaging data of serotonin transporter occupancy by SSRIs and found that hyperbolically reducing doses of SSRIs reduces their effect on serotonin transporter inhibition in a linear manner. We therefore suggest that SSRIs should be tapered hyperbolically and slowly to doses much lower than those of therapeutic minimums”

 

How long have we all known this now? 😄

Medication before problems: Took Paxil 60-100mg from 2003 to 2014 for OCD.
1) Last pill taken November 2014, horrendous withdrawal started six weeks later.

2) Re-instated successfully @ 20mg May 2015, but accompanied by severe anhedonia, loss of emotion, apathy, and fatigue

3) Switched to Prozac, Viibyrd, Zoloft, Nefazadone, Cymbalta, Nardil in attempt at abating WD symptoms while not re-introducing anhedonia. Each one either failed to relieve WD or brought back anhedonia. So re-stabilized on Paxil at 15mg

4) Tapered down to 7.5mg as of October 2016. More energy, anhedonia/loss of emotions remains apart from short windows.

5) May 2017 - down to 3.5mg of Paxil (no other meds)
6) Early 2018 - added 8mg of Prozac
7) January 2019 - down to 1.05 Paxil / 5mg Prozac and continuing

8) October 2019 - down to 0.2mg Paxil / 3mg Prozac

9) November 2019 - down to 0.1mg Paxil / 3mg Prozac 

10) March 2020 - done with Paxil, 2.5mg Prozac

11) April 2021 - 0.03mg Prozac

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SurvivingAntidepressants.org topic Why taper? SERT transporter occupancy studies show importance of gradual change in plasma concentration  and other tapering discussions informed Dr. Horowitz's thinking.

 

Also see

 

This is not medical advice. Discuss any decisions about your medical care with a knowledgeable medical practitioner.

"It has become appallingly obvious that our technology has surpassed our humanity." -- Albert Einstein

All postings © copyrighted.

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Hi All,

 

I wrote to [Dr. Horowitz] last week and he sent me a copy very quickly, which as nice of him. He is also looking for further funding to do more research in this area. I had to compress the pdf and zip it up to get within the limits allowed by the forum. If anyone wants a copy of the original, message me you're email address.

Cheers

Capsur

 

Edited by Altostrata
removed copyrighted material

2011 - started Venlafaxine (again) at 75mg Raised to 150 mg at some point - unsure of dates. Reduced back down to 75 mg. Doctor advised this would be a lifetime, maintenance dose

2017 - Side effects now intolerable. Started taper from June 15th - 5% dose reduction steps (two 12 hourly doses).

2017 - October 20th - took last dose of Venlafaxine - 4 mg. Debilitating symptoms followed.

2017/18 - diazepam - 8mg/day for 1 month - 7 week taper Feb 2018

2017/18 - duloxetine - max 90mg - now stopped

2018 - Feb 25mg quetiapine, increased to 50mg.

2018 - March/April - increased venlafaxine slowly (10mg steps) to 75 mg/day. Recovery from withdrawal followed.

2018 - July 13 - stopped quetiapine after 2 month taper. Late July - had to reinstate quetiapine due to intolerable withdrawal. Now tapering from 25mg

2019 - June - stopped quetiapine after 10 month taper. Mild insomnia only symptom.

2021 - June - venlafaxine approx 6.0 mg see Taper history details

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There's also been some news coverage on this paper in the UK. Not sure I like the title of the article as it implies the drugs are not taken long enough!

 

https://www.thetimes.co.uk/article/depressed-patients-stop-pills-too-hastily-gps-told-20f7vtmsk?fbclid=IwAR2F_z42eQgvnFPyZjeDYBMSJptfM-90x8XpYAEZYCmdqsrhj-X8si7ilDE

 

Here's full text of TIMES articleincase you can't access it: Coming off antidepressants can take months and doctors must not rush patients into stopping, experts say.
Patients benefit from tapering off the drugs over nine months to avoid getting trapped on the medicines by debi
litating withdrawal symptoms, they argue.
Brain scans show that current methods of stopping can lead to abrupt changes that could be avoided with more gradual dose reductions, according to a review of research published in The Lancet Psychiatry.
More than seven million people in England are on antidepressants and the number has been rising. They have been shown to work for severe depression but many patients experience withdrawal symptoms. Critics of current methods say these are often mistaken for the return of depression, leading to people being put back on medication long term.
A review into the problem has been beset by rows and current guidelines recommend halving the dose for four weeks before stopping to avoid symptoms. However, David Taylor of King’s College London and Mark Horowitz, a training psychiatrist at the Prince of Wales Hospital in Sydney, argue that this is wrong. “When you halve the dose of your antidepressant once you don’t decrease the action of the drug very much at its target receptors. But when you reduce the drug to 0mg from half the dose you go down a huge amount in effect at receptors,” Dr Horowitz said.
“We suggest that this is why people get into trouble when they taper — they are going down too fast. We therefore suggest that patients should halve their dose a number of times before stopping, which will mean the drop in effect at receptors is much more gradual.”
He proposes halving doses six times over many months, arguing: “There is no downside to doing our technique. All we are saying is go slower.” Dr Horowitz, who struggled to come off antidepressants himself, added: “If I hadn’t had my own experience of this I wouldn’t have believed it either.”
Professor Taylor said: “Doctors and patients need better evidence on how to taper people off safely and carefully.”
James Davies of the Council for Evidence-based Psychiatry, a critic of current methods, said: “We have sufficient evidence to update our guidelines. . . for many people a 2-4 week taper is far, far too fast and very dangerous.”

Carmine Pariante of the Royal College of Psychiatrists said: “When withdrawal is properly managed, most patients can come off them with minimal side-effects or with side-effects that can be managed with the help of their doctor, by slowing or stopping over four weeks. However, we know this is not the case for all patients . . . While this paper is an important theoretical contribution, the recommended protocols will need to be tested to ensure they work.”

 

Cheers

Caspur

Edited by Caspur
Added full text

2011 - started Venlafaxine (again) at 75mg Raised to 150 mg at some point - unsure of dates. Reduced back down to 75 mg. Doctor advised this would be a lifetime, maintenance dose

2017 - Side effects now intolerable. Started taper from June 15th - 5% dose reduction steps (two 12 hourly doses).

2017 - October 20th - took last dose of Venlafaxine - 4 mg. Debilitating symptoms followed.

2017/18 - diazepam - 8mg/day for 1 month - 7 week taper Feb 2018

2017/18 - duloxetine - max 90mg - now stopped

2018 - Feb 25mg quetiapine, increased to 50mg.

2018 - March/April - increased venlafaxine slowly (10mg steps) to 75 mg/day. Recovery from withdrawal followed.

2018 - July 13 - stopped quetiapine after 2 month taper. Late July - had to reinstate quetiapine due to intolerable withdrawal. Now tapering from 25mg

2019 - June - stopped quetiapine after 10 month taper. Mild insomnia only symptom.

2021 - June - venlafaxine approx 6.0 mg see Taper history details

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All,

Further coverage of the Horowitz paper in the Daily Mail, UK.

https://www.dailymail.co.uk/health/article-6797517/Proof-getting-depression-pills-without-crippling-effects-MONTHS.html

Cheers

Caspur

2011 - started Venlafaxine (again) at 75mg Raised to 150 mg at some point - unsure of dates. Reduced back down to 75 mg. Doctor advised this would be a lifetime, maintenance dose

2017 - Side effects now intolerable. Started taper from June 15th - 5% dose reduction steps (two 12 hourly doses).

2017 - October 20th - took last dose of Venlafaxine - 4 mg. Debilitating symptoms followed.

2017/18 - diazepam - 8mg/day for 1 month - 7 week taper Feb 2018

2017/18 - duloxetine - max 90mg - now stopped

2018 - Feb 25mg quetiapine, increased to 50mg.

2018 - March/April - increased venlafaxine slowly (10mg steps) to 75 mg/day. Recovery from withdrawal followed.

2018 - July 13 - stopped quetiapine after 2 month taper. Late July - had to reinstate quetiapine due to intolerable withdrawal. Now tapering from 25mg

2019 - June - stopped quetiapine after 10 month taper. Mild insomnia only symptom.

2021 - June - venlafaxine approx 6.0 mg see Taper history details

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It made the New York Times
https://www.nytimes.com/2019/03/05/health/depression-withdrawal-drugs.html

 

Quote

But the brain-imaging studies found that inhibition of the transporter increases sharply with addition of the drug and, by extension, also drops sharply with any reduction in dosage. The standard medical advice, to reduce dosage by half — for instance, by taking a pill every other day — and end medication entirely after four weeks, does not take this into account, the two researchers argued.

“Doctors have in mind that these drugs act in a linear way, that when you reduce dosage by half, it reduces the effect in the brain by a half,” Dr. Horowitz said. “It doesn’t work that way. And as a result, there’s a huge load in terms of the effect on brain receptors, and patients are being advised to come off way too quickly.”


Discussion of this has been largely confined to forums like this one, even though people discovered they needed to taper to tiny fractions of the therapeutic dose to get off paxil more than a decade ago - now it's out there and it's finally being regarded as credible.

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  • 2 weeks later...

Thank you @Henosis and @dcrmt.

 

The fact that it made the NYT is great. I loved this comment especially:

 

"Daniel Smith
Leverett, MA

March 8
Well it's about time. I went through this years ago, when it was still mostly unrecognized. I ran into an acquaintance who is an addiction counselor and, with trepidation, told him what I was experiencing. He said, without missing a beat, "Yeah, it's actually worse than heroin because it just goes on and on and on--everyone in my business knows that. And what makes it worse is that there's no socially acceptable narrative. If you get off heroin, everyone knows that's incredibly hard and that you've done something heroic. With this stuff, people think you're making it up, because it's supposed to be a  nice medicine that some smart doctor gave you." Those words helped me get through it and I'm glad people now can find more support. What I especially love is the last line of this article. Why in the world would a doctor believe the experience of patients when it's not in the textbooks?!" 

 

One day, perhaps it will become common knowledge that SSRI withdrawal is a condition that requires more support and help than probably any of the conditions for which these drugs are prescribed. I can vouch for that, anecdotally of course, having now recovered from OCD with CBT alone and I found it so much easier than SSRI withdrawal!

2012: 2 weeks of paroxetine, I cannot recall the dose. Strong side effects, stopped cold turkey, had intense, horrible withdrawal thereafter

2012 to 2016: Fluoxetine 40mg daily, sometimes 20mg daily, a couple of bad tapers under doctor's advisement, increasingly bad withdrawal symptoms with each major dose change

Oct 2016 to June 2017: 10-month reinstatement of 20mg fluoxetine daily to stabilize. A very difficult period but withdrawal gradually improved

July 2017: At 20mg (100%), started a linear tapering regimen using water titration (20mg fluoxetine into 300ml of water).

June 2019: Currently at 0.200mg (1.00%). I have many symptoms, most I attribute to fluoxetine, some to withdrawal, and the rest to hypothyroidism. Continuing to reduce anyway.

July 2019: Jumped from 0.066mg (0.33%) to 0.000mg (0.00%); I'm now free of the poison.

 

My introduction thread: https://www.survivingantidepressants.org/topic/14226-kittygiggles-generic-prozac-fluoxetine-stabilization/

 

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  • 1 month later...

If the the lower doses of Drugs have the vast majority of receptors locked down, why bother  for instance tapering down from 50mg of Sertraline in 10percent steps when you could just go from 50mg to say 12mg directly and then taper down slowly from 12mg to 0mg. The advice does not stack up against the occupancy curves. 

May 2007 - October 2007 Citalopram 20 mg od. 1st Antidepressant ever taken. No problem with fast taper and no withdrawal effects. No antidepressants for over 5 years.

 

January 2013 started Citalopram 20mg.

March 2014 Switched to Sertraline 50 mg od.

23rd June 2016 started taper 45mg

23.07.16 40.5mg 23.08.16 36.45mg 27.09.16 34.65mg 24.10.16 32.90mg 28.11.16 31.26mg 04.01.17 32mg 25.02.17 31mg 22.03.17 30mg 14.04.17 29mg 09.05.17 28mg 07.06.17 27mg 08.06.17 26mg 13.07.17 25mg 07.08.17 24mg 24.08.17 23mg 13.09.17 22mg 12.10.17 21mg 10.11.17 20mg 04.12.17 19mg 01.01.18 17mg 25.01.18 15mg 22.02.18 13.5mg 25.03.18 12.15mg 

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10 hours ago, Altostrata said:

It's likely that many people are taking dosages with excess capacity, i.e., they could reduce by 25% and still maintain full SERT saturation, then taper by 10% from there.

 

HOWEVER, we don't know what your individual curve looks like. It could be that a quarter of your dosage saturates your SERT receptors, or it could be that you need 90% for saturation, and a 25% reduction might throw you into acute withdrawal.

 

Admittedly -- we make this clear -- an initial 10% reduction is very cautious. But being that we only offer peer support over the Internet, we can't rescue you should you reduce by 25% and panic because you have severe symptoms. So we advise everyone to go the more cautious route of 10%, where if you do get withdrawal symptoms from tapering, they are less likely to be severe.

 

This is not medical advice. Discuss any decisions about your medical care with a knowledgeable medical practitioner.

"It has become appallingly obvious that our technology has surpassed our humanity." -- Albert Einstein

All postings © copyrighted.

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Another commentary on this paper, this time in Neurology Today https://journals.lww.com/neurotodayonline/Fulltext/2019/04180/Avoiding_Withdrawal_Syndrome_for_SSRIs_Requires.4.aspx


 

Quote

 

Avoiding Withdrawal Syndrome for SSRIs Requires Months, Not Weeks, and a More Gradual Curve, Paper Concludes

....

“I have seen the withdrawal effect; it can go on for months,” said Richard B. Lipton, MD, FAAN, the Edwin S. Lowe Professor and vice chair of neurology at Albert Einstein College of Medicine, where he is also director of the Montefiore Headache Center. “I definitely agree with the authors of this paper on the need for more gradual tapering in some patients. I've certainly had certain patients buy pill cutters to cut an already low dose of an SSRI into quarters and take them daily, then take them every other day, to try to make the taper more comfortable.”

 

Dr. Lipton said he also agreed with the authors of the paper that current guidelines on tapering SSRIs should be reconsidered, and that randomized, controlled trials would be useful to more rigorously test the effects of a slower, more gradual tapering protocol.....

....

Expert Commentary

Mamatha Pasnoor, MD, associate professor of neurology at the University of Kansas, noted that the standard dose for duloxetine for the treatment of diabetic neuropathy is much lower, at 60 mg, than is typically used for depression, which can be up to 120 mg.

 

“If they're only on 60 milligrams, you're tapering them over just a few weeks,” Dr. Pasnoor said. “The maximum amount of time I've used is a month or so. I haven't seen any issues with my patients at tapering from that dose.”

 

Michael Polydefkis, MD, MHS, professor of neurology at Johns Hopkins School of Medicine, said he has become more conservative over the years in tapering antidepressants, including SNRIs and tricyclics, when treating neuropathy.

 

“Some people can taper quickly, others need to go very slowly, over several months,” he said. “It's very idiosyncratic. But it's certainly never taken a patient of mine a year to taper off completely.”

 

Rebecca C. Burch, MD, assistant professor of neurology at Harvard Medical School and a headache specialist at the John R. Graham Headache Center, recalled one patient who required two years to taper off an SNRI.

 

“But the vast majority of my patients can do it within three or four months,” she emphasized. “Most patients with migraine seem to be susceptible to acute changes in any of their medications. As a result, headache specialists have developed a practice of starting medications at relatively low doses and increasing slowly. Likewise, when we're in the process of discontinuing a medication, we taper down slowly too.”

 

She agreed with the paper's conclusion that tapering should be individualized based on the patient's response.

 

“Putting it in the patients' hands is the most important thing,” Dr. Burch said. “Some want to decrease as rapidly as every four days. Others choose to do so once a month.”

 

The new paper, she said, “starts to build a body of evidence that will help us understand how best to taper SSRIs, and possibly SNRIs, in the future. I don't think it's conclusive enough to warrant widespread changes for now, but as more studies come out, we hopefully will better understand how best to approach the use of these important medications.”

 

Dr. Lipton, who led the Chronic Migraine Epidemiology and Outcomes (CaMEO) study as well as the American Migraine Prevalence and Prevention (AMPP) study, noted that both studies showed that the frequency of migraines varies dramatically over time. As a result, he said, it's not surprising that patients' use of antidepressants, whether SNRIs or SSRIs, can wax and wane.

 

“I always tell people, if you're tapering an SSRI, you have to go by how you feel,” Dr. Lipton said. “It's not a race. You can always taper more slowly.”

Rather than taper over a single month, he said, “My usual taper is over two months. But if someone is tapering an SSRI and feels uncomfortable at that rate, it makes sense to go more slowly and keep the patient comfortable.”

 

While he has not studied the pharmacokinetics of tapering antidepressants, Dr. Lipton said, “I've come to my approach just by listening to what the patients were saying. It feels like common sense to say that tapering should be individualized and slowed down. I don't think it's rocket science. But I'm glad there's a paper in Lancet Psychiatry describing a phenomenon I've seen.”

 

 

This is not medical advice. Discuss any decisions about your medical care with a knowledgeable medical practitioner.

"It has become appallingly obvious that our technology has surpassed our humanity." -- Albert Einstein

All postings © copyrighted.

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On 5/19/2019 at 9:16 PM, Lakelander82 said:

If the the lower doses of Drugs have the vast majority of receptors locked down, why bother  for instance tapering down from 50mg of Sertraline in 10percent steps when you could just go from 50mg to say 12mg directly and then taper down slowly from 12mg to 0mg. The advice does not stack up against the occupancy curves. 

 

 

Escitalopram 1.05 mg (max of 30 mg, taper from 10 mg to now started september 2016)

 

Klonopin 0.3 mg (one dosage reduction of 25 percent, from 0.4 to 0.3 mg september 2017)

 

Supplements: magnesium malate, fish oil, curcumin, multivitamin, iodine, probiotics, vitamine D along with eating healthy 80 percent of the time, I have no problem whatsoever taking supplements.

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Do you have a question, @Linus?

 

Please note: Questions and remarks are more productive IF YOU READ THE PAPER FIRST before commenting.

This is not medical advice. Discuss any decisions about your medical care with a knowledgeable medical practitioner.

"It has become appallingly obvious that our technology has surpassed our humanity." -- Albert Einstein

All postings © copyrighted.

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  • 2 weeks later...

What you can try is look at the receptor occupancy vs dosage chart. Don’t use the x axis, instead use the y axis ie. occupancy %. Find your current dose, then on the y axis make 10% divisions and see what the corresponding dosage is on the x axis.

 

this dosage is your new dose every month. I think one will find that at the lower end the dose becomes microdosing to get the same 10% occupancy drop as with any exponential function or rather it’s a hyperbolic function. The dosage at low doses is compressed for the same 10% drop in receptor occupancy

 

Lexapro

10mg 11/2018 -  4 weeks

20mg 12/2018 - 4 weeks

20mg - 0mg - 01/2019 - 02/2019  - taper 6 weeks - WD symptoms

10mg - 03/2019 - 6 week reinstate

03-04/2019 taper 10,7.5,5,2.5,0mg as instructed by dr.

0mg - 04-06/2019 - WD symptoms again.

accute symptom cleared follow by protracted symptoms still ongoing

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On 6/2/2019 at 8:29 PM, TriD said:

this dosage is your new dose every month.

 

It's important to listen to your body and symptoms and not a calendar or a formula.

* NO LONGER ACTIVE on SA *

MISSION ACCOMPLISHED:  (6 year taper)      0mg Pristiq  on 13th November 2021

ADs since ~1992:  25+ years - 1 unknown, Prozac (muscle weakness), Zoloft; citalopram (pooped out) CTed (very sick for 2.5 wks a few months after); Pristiq:  50mg 2012, 100mg beg 2013 (Serotonin Toxicity)  Tapering from Oct 2015 - 13 Nov 2021   LAST DOSE 0.0025mg

Post 0 updates start here    My tapering program     My Intro (goes to tapering graph)

 VIDEO:   Antidepressant Withdrawal Syndrome and its Management

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On 6/9/2019 at 2:48 PM, ChessieCat said:

 

It's important to listen to your body and symptoms and not a calendar or a formula.

Yes i do this.. but i mean the formula as a guide and also go by how we feel at each dose in making the next decision.

Lexapro

10mg 11/2018 -  4 weeks

20mg 12/2018 - 4 weeks

20mg - 0mg - 01/2019 - 02/2019  - taper 6 weeks - WD symptoms

10mg - 03/2019 - 6 week reinstate

03-04/2019 taper 10,7.5,5,2.5,0mg as instructed by dr.

0mg - 04-06/2019 - WD symptoms again.

accute symptom cleared follow by protracted symptoms still ongoing

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  • 2 weeks later...
  • Moderator
On 3/11/2019 at 10:51 AM, Caspur said:

Carmine Pariante of the Royal College of Psychiatrists said: “When withdrawal is properly managed, most patients can come off them with minimal side-effects or with side-effects that can be managed with the help of their doctor, by slowing or stopping over four weeks. However, we know this is not the case for all patients . . . While this paper is an important theoretical contribution, the recommended protocols will need to be tested to ensure they work.

 

Right, because the current methods have been tested and shown to work! The audacity!

"Nothing so small as a moment is insurmountable, and moments are all that we have. You have survived every trial and tribulation that life has thrown at you up until this very instant. When future troubles come—and they will come—a version of you will be born into that moment that can conquer them, too." - Kevin Koenig 

 

I am not a doctor and this should not be considered medical advice. You can use the information and recommendations provided in whatever way you want and all decisions on your treatment are yours. 

 

In the next few weeks I do not have a lot of capacity to respond to questions. If you need a quick answer pls tag or ask other moderators who may want to be tagged. 

 

Aug  2000 - July 2003 (ct, 4-6 wk wd) , citalopram 20 mg,  xanax prn, wellbutrin for a few months, trazodone prn 

Dec 2004 - July 2018 citalopram 20 mg, xanax prn (rarely used)

Aug 2018 - citalopram 40 mg (self titrated up)

September 2018 - January 2019 tapered citalopram - 40/30/20/10/5 no issues until a week after reaching 0

Feb 2019 0.25 xanax - 0.5/day (3 weeks) over to klonopin 0.25 once a day to manage severe wd

March 6, reinstated citalopram 2.5 mg (liquid), klonopin 0.25 mg for sleep 2-3 times a week

Apr 1st citalopram 2.0 mg (liquid), klonopin 0.25 once a week (off by 4/14/19- no tapering)

citalopram (liquid) 4/14/19 -1.8 mg, 5/8/19 - 1.6 mg,  7/27/19 -1.5 mg,  8/15/19 - 1.35, 2/21/21 - 1.1 (smaller drops in between), 6/20/21 - 1.03 mg, 8/7/21- 1.025, 8/11/21 - 1.02, 8/15/21 - 1.015, 9/3/21 - 0.925 (fingers crossed!), 10/8/21 - 0.9, 10/18/21 - 0.875, 12/31/21 - 0.85, 1/7/22 - 0.825, 1/14/22 - 0.8, 1/22/22 - 0.785, 8/18/22 - 0.59, 12/15/2022 - 0.48, 2/15/22 - 0.43, 25/07/23 - 0.25 (mistake), 6/08/23 - 0.33mg

 

Supplements: magnesium citrate and bi-glycinate

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Seems that there are a bunch of new articles as a response to the Horrowitz and Taylor (2019) article.

 

One from the Netherlands Antidepressant Discontinuation Taskforce

https://www.thelancet.com/journals/lanpsy/article/PIIS2215-0366(19)30182-8/fulltext

 

one from the guys in the pocket of Pharma (check out their conflicts of interest!) - denying that withdrawal is common

https://www.thelancet.com/journals/lanpsy/article/PIIS2215-0366(19)30183-X/fulltext

 

(NB: Can someone other than me also check the references for this article - I am looking at 2,3,4 and they don't seem to be saying what the authors of this aricle claim they do, quite the opposite. Am I misunderstanding something?)

 

And another denial (discontinuation is a nocebo effect apparently! especially because now it is being talked about in the news) 

https://www.thelancet.com/journals/lanpsy/article/PIIS2215-0366(19)30184-1/fulltext

 

This is a bit disheartening as it will be used by the pharma people to deny withdrawal. I did not expect to have withdrawal effects. In fact, they caught me by surprise. Only then did I find SA. That is true for the majority of people I see here. These people claim that in the clinic wd effects are not observed but how could they be when the GPs keep denying things and not believing their patients as so many of us can attest. None of us wants to make these things up because they are not fun. In fact with every window I expect I am healed only to be thrown to bed for a few days. Placebo should be at work with windows not nocebo.

"Nothing so small as a moment is insurmountable, and moments are all that we have. You have survived every trial and tribulation that life has thrown at you up until this very instant. When future troubles come—and they will come—a version of you will be born into that moment that can conquer them, too." - Kevin Koenig 

 

I am not a doctor and this should not be considered medical advice. You can use the information and recommendations provided in whatever way you want and all decisions on your treatment are yours. 

 

In the next few weeks I do not have a lot of capacity to respond to questions. If you need a quick answer pls tag or ask other moderators who may want to be tagged. 

 

Aug  2000 - July 2003 (ct, 4-6 wk wd) , citalopram 20 mg,  xanax prn, wellbutrin for a few months, trazodone prn 

Dec 2004 - July 2018 citalopram 20 mg, xanax prn (rarely used)

Aug 2018 - citalopram 40 mg (self titrated up)

September 2018 - January 2019 tapered citalopram - 40/30/20/10/5 no issues until a week after reaching 0

Feb 2019 0.25 xanax - 0.5/day (3 weeks) over to klonopin 0.25 once a day to manage severe wd

March 6, reinstated citalopram 2.5 mg (liquid), klonopin 0.25 mg for sleep 2-3 times a week

Apr 1st citalopram 2.0 mg (liquid), klonopin 0.25 once a week (off by 4/14/19- no tapering)

citalopram (liquid) 4/14/19 -1.8 mg, 5/8/19 - 1.6 mg,  7/27/19 -1.5 mg,  8/15/19 - 1.35, 2/21/21 - 1.1 (smaller drops in between), 6/20/21 - 1.03 mg, 8/7/21- 1.025, 8/11/21 - 1.02, 8/15/21 - 1.015, 9/3/21 - 0.925 (fingers crossed!), 10/8/21 - 0.9, 10/18/21 - 0.875, 12/31/21 - 0.85, 1/7/22 - 0.825, 1/14/22 - 0.8, 1/22/22 - 0.785, 8/18/22 - 0.59, 12/15/2022 - 0.48, 2/15/22 - 0.43, 25/07/23 - 0.25 (mistake), 6/08/23 - 0.33mg

 

Supplements: magnesium citrate and bi-glycinate

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On 6/28/2019 at 2:01 PM, Onmyway said:

one from the guys in the pocket of Pharma (check out their conflicts of interest!) - denying that withdrawal is common

https://www.thelancet.com/journals/lanpsy/article/PIIS2215-0366(19)30183-X/fulltext

 

Here is the response from Horowitz and Taylor: https://www.thelancet.com/journals/lanpsy/article/PIIS2215-0366(19)30219-6/fulltext

 

"Minimisation of the scale and severity of withdrawal alongside somewhat vague prescriptions for tapering is not a rational way forward."

Escitalopram 1.05 mg (max of 30 mg, taper from 10 mg to now started september 2016)

 

Klonopin 0.3 mg (one dosage reduction of 25 percent, from 0.4 to 0.3 mg september 2017)

 

Supplements: magnesium malate, fish oil, curcumin, multivitamin, iodine, probiotics, vitamine D along with eating healthy 80 percent of the time, I have no problem whatsoever taking supplements.

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  • Moderator

 

Brilliant! I love how their response is measured and to the point without attempts at snide remarks and minimization! Thanks for posting it Linus!

"Nothing so small as a moment is insurmountable, and moments are all that we have. You have survived every trial and tribulation that life has thrown at you up until this very instant. When future troubles come—and they will come—a version of you will be born into that moment that can conquer them, too." - Kevin Koenig 

 

I am not a doctor and this should not be considered medical advice. You can use the information and recommendations provided in whatever way you want and all decisions on your treatment are yours. 

 

In the next few weeks I do not have a lot of capacity to respond to questions. If you need a quick answer pls tag or ask other moderators who may want to be tagged. 

 

Aug  2000 - July 2003 (ct, 4-6 wk wd) , citalopram 20 mg,  xanax prn, wellbutrin for a few months, trazodone prn 

Dec 2004 - July 2018 citalopram 20 mg, xanax prn (rarely used)

Aug 2018 - citalopram 40 mg (self titrated up)

September 2018 - January 2019 tapered citalopram - 40/30/20/10/5 no issues until a week after reaching 0

Feb 2019 0.25 xanax - 0.5/day (3 weeks) over to klonopin 0.25 once a day to manage severe wd

March 6, reinstated citalopram 2.5 mg (liquid), klonopin 0.25 mg for sleep 2-3 times a week

Apr 1st citalopram 2.0 mg (liquid), klonopin 0.25 once a week (off by 4/14/19- no tapering)

citalopram (liquid) 4/14/19 -1.8 mg, 5/8/19 - 1.6 mg,  7/27/19 -1.5 mg,  8/15/19 - 1.35, 2/21/21 - 1.1 (smaller drops in between), 6/20/21 - 1.03 mg, 8/7/21- 1.025, 8/11/21 - 1.02, 8/15/21 - 1.015, 9/3/21 - 0.925 (fingers crossed!), 10/8/21 - 0.9, 10/18/21 - 0.875, 12/31/21 - 0.85, 1/7/22 - 0.825, 1/14/22 - 0.8, 1/22/22 - 0.785, 8/18/22 - 0.59, 12/15/2022 - 0.48, 2/15/22 - 0.43, 25/07/23 - 0.25 (mistake), 6/08/23 - 0.33mg

 

Supplements: magnesium citrate and bi-glycinate

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On 3/11/2019 at 10:49 AM, Caspur said:

Hi All,

 

I wrote to [Dr. Horowitz] last week and he sent me a copy very quickly, which as nice of him. He is also looking for further funding to do more research in this area. I had to compress the pdf and zip it up to get within the limits allowed by the forum. If anyone wants a copy of the original, message me you're email address.

Cheers

Capsur

 

Hi Capsur

I would like a copy please to show my GP.  How do I PM you my email?

Thanks MissyE

MissyE

2008 Dec-Feb 2009 GP diazipam; Dec-Jun 2009 fluoxetine. 2010 Jan citalopram approx 4 weeks, Jan- Aug fluox, Oct-Jun 2011 paroxetine; Aug - Dec venlafaxine 37.5mg - 75mg. 2012 Mar-Jul reinstate ven 150mg; Aug swap to fluox 40mg (preg) - Mar 2013  reinstate ven 150mg. 2015 Nov swap to fluox 40mg (preg) Dec suicidal reinstated ven 300mg

2018 Jan ven "pooped" buspirone added/stopped; pentagablin added; March pent stopped & ven taper - 0 June; August betablockers started/ stopped; September mirtazapine 15mg and diazepam 2mg started/stopped; October ven 300mg reinstated. 

2019 Jan psychiatrist added mirt 15mg (aiming for "California rocket fuel" therapeutic dose).  No more meds: gradual taper mirt Feb-April (taken for < 3 weeks).

Commenced ven taper 5-10% 6-10 weekly 2019 April - Nov: 225mg.  Tapering 8 weekly in alignment with menstrual cycle 2020 Jan 212.5mg; Mar 200mg; Jun 187.5mg hold

Oct all meds stopped sectioned under mental health act psychosis olanzapine 20mg PRN lorazepam

Dec 600mg lithium 15mg olanzapine

1-2g omega 3 & 400ug folic acid

2 puffs pulmicort inhaler.

This too shall pass.

 

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  • Moderator Emeritus
3 hours ago, MissyE said:

How do I PM you my email?

 

I've sent you a PM explaining how to do this.  Top right of the screen you will see an Envelope to click on.

* NO LONGER ACTIVE on SA *

MISSION ACCOMPLISHED:  (6 year taper)      0mg Pristiq  on 13th November 2021

ADs since ~1992:  25+ years - 1 unknown, Prozac (muscle weakness), Zoloft; citalopram (pooped out) CTed (very sick for 2.5 wks a few months after); Pristiq:  50mg 2012, 100mg beg 2013 (Serotonin Toxicity)  Tapering from Oct 2015 - 13 Nov 2021   LAST DOSE 0.0025mg

Post 0 updates start here    My tapering program     My Intro (goes to tapering graph)

 VIDEO:   Antidepressant Withdrawal Syndrome and its Management

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Thank you

MissyE

2008 Dec-Feb 2009 GP diazipam; Dec-Jun 2009 fluoxetine. 2010 Jan citalopram approx 4 weeks, Jan- Aug fluox, Oct-Jun 2011 paroxetine; Aug - Dec venlafaxine 37.5mg - 75mg. 2012 Mar-Jul reinstate ven 150mg; Aug swap to fluox 40mg (preg) - Mar 2013  reinstate ven 150mg. 2015 Nov swap to fluox 40mg (preg) Dec suicidal reinstated ven 300mg

2018 Jan ven "pooped" buspirone added/stopped; pentagablin added; March pent stopped & ven taper - 0 June; August betablockers started/ stopped; September mirtazapine 15mg and diazepam 2mg started/stopped; October ven 300mg reinstated. 

2019 Jan psychiatrist added mirt 15mg (aiming for "California rocket fuel" therapeutic dose).  No more meds: gradual taper mirt Feb-April (taken for < 3 weeks).

Commenced ven taper 5-10% 6-10 weekly 2019 April - Nov: 225mg.  Tapering 8 weekly in alignment with menstrual cycle 2020 Jan 212.5mg; Mar 200mg; Jun 187.5mg hold

Oct all meds stopped sectioned under mental health act psychosis olanzapine 20mg PRN lorazepam

Dec 600mg lithium 15mg olanzapine

1-2g omega 3 & 400ug folic acid

2 puffs pulmicort inhaler.

This too shall pass.

 

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  • 3 weeks later...
  • Moderator

I was rereading this paper today and noted that they don't actually advocate a reduction of 10 % of previous dose but rather a 10% reduction in occupancy rate from previous dose. For Citalopram, I am posting the table which comes from the formula they use to derive their SERT occupancy curve. Note that this is not in line with SA's recommendations.  

 

Source: 

Published:March 05, 2019 The Lancet DOI:https://doi.org/10.1016/S2215-0366(19)30032-X

Tapering of SSRI treatment to mitigate withdrawal symptoms by Horowitz, M.A. and Taylor, D. 

 

Table 2. Derivation of SERT occupancy from citalopram dose using the Michaelis-Menten equation of best fit

Citalopram dose (mg) SERT occupancy (%)
60·0 87·8%
40·0 85·9%
20·0 80·5%
19·0 80·0%
9·1 70·0%
5·4 60·0%
3·4 50·0%
2·3 40·0%
1·5 30·0%
0·8 20·0%
0·37 10·0%

 

SERT occupancy was calculated using the Michaelis-Menten equation of best fit derived by Meyer and colleagues.60 Common clinical doses and doses corresponding to 10% decrements of SERT inhibition are displayed. These doses could be produced by a combination of tablets and liquid formulations. Approximations might be necessary. SERT=serotonin transporter."

 

"Nothing so small as a moment is insurmountable, and moments are all that we have. You have survived every trial and tribulation that life has thrown at you up until this very instant. When future troubles come—and they will come—a version of you will be born into that moment that can conquer them, too." - Kevin Koenig 

 

I am not a doctor and this should not be considered medical advice. You can use the information and recommendations provided in whatever way you want and all decisions on your treatment are yours. 

 

In the next few weeks I do not have a lot of capacity to respond to questions. If you need a quick answer pls tag or ask other moderators who may want to be tagged. 

 

Aug  2000 - July 2003 (ct, 4-6 wk wd) , citalopram 20 mg,  xanax prn, wellbutrin for a few months, trazodone prn 

Dec 2004 - July 2018 citalopram 20 mg, xanax prn (rarely used)

Aug 2018 - citalopram 40 mg (self titrated up)

September 2018 - January 2019 tapered citalopram - 40/30/20/10/5 no issues until a week after reaching 0

Feb 2019 0.25 xanax - 0.5/day (3 weeks) over to klonopin 0.25 once a day to manage severe wd

March 6, reinstated citalopram 2.5 mg (liquid), klonopin 0.25 mg for sleep 2-3 times a week

Apr 1st citalopram 2.0 mg (liquid), klonopin 0.25 once a week (off by 4/14/19- no tapering)

citalopram (liquid) 4/14/19 -1.8 mg, 5/8/19 - 1.6 mg,  7/27/19 -1.5 mg,  8/15/19 - 1.35, 2/21/21 - 1.1 (smaller drops in between), 6/20/21 - 1.03 mg, 8/7/21- 1.025, 8/11/21 - 1.02, 8/15/21 - 1.015, 9/3/21 - 0.925 (fingers crossed!), 10/8/21 - 0.9, 10/18/21 - 0.875, 12/31/21 - 0.85, 1/7/22 - 0.825, 1/14/22 - 0.8, 1/22/22 - 0.785, 8/18/22 - 0.59, 12/15/2022 - 0.48, 2/15/22 - 0.43, 25/07/23 - 0.25 (mistake), 6/08/23 - 0.33mg

 

Supplements: magnesium citrate and bi-glycinate

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  • 2 weeks later...
On 7/26/2019 at 7:28 PM, Onmyway said:

I was rereading this paper today and noted that they don't actually advocate a reduction of 10 % of previous dose but rather a 10% reduction in occupancy rate from previous dose. For Citalopram, I am posting the table which comes from the formula they use to derive their SERT occupancy curve. Note that this is not in line with SA's recommendations. 

 

Correct, and because of that probably still too fast for some people IMO.

Escitalopram 1.05 mg (max of 30 mg, taper from 10 mg to now started september 2016)

 

Klonopin 0.3 mg (one dosage reduction of 25 percent, from 0.4 to 0.3 mg september 2017)

 

Supplements: magnesium malate, fish oil, curcumin, multivitamin, iodine, probiotics, vitamine D along with eating healthy 80 percent of the time, I have no problem whatsoever taking supplements.

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I agree much too fast, but interesting that they're talking about this concept.

2005 St John's Wort / 2006-2012 Lexapro 20mg, 2 failed attempts to stop, tapered over 4.5 months in early 2012

January 2013 started Sertraline, over time worked up to 100mg

July 2014 Sertraline dropped from 100mg to 75mg, held for six months, slower tapering until 2019 22 Dec 3.2mg

2020 Sertraline 19 Jan 3.1mg, 26 Jan 3.0mg; 1 Mar 2.9, 7 Mar 2.8, May (some drops here) 24 May 2.5, May 29 2.4, June 21 2.3, June 28 2.2mg,  July 4 2.1mg, July 24 (or maybe a bit before) 2mg, early Nov switched to home made suspension; 29 Nov 1.8mg; approx 25 Dec 1.6mg)

2021 Some time in about Jan/Feb realised probably on more like 1.8mg and poss mixing error in making suspension; doses after 10 Feb accurate; 10 Feb 1.6mg; 7 Mar 1.4, continued monthly

10% drops until 1mg, then dropped 0.1mg monthly.

May 2022,0.1mg, now dropping 0.01mg per week

29 August 2022 - first day of zero!

My thread here at SA: https://www.survivingantidepressants.org/topic/1775-bubbles/page/21/

Current: Armour Thyroid

 

 

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On 3/11/2019 at 9:49 PM, Caspur said:

Hi All,

 

I wrote to [Dr. Horowitz] last week and he sent me a copy very quickly, which as nice of him. He is also looking for further funding to do more research in this area. I had to compress the pdf and zip it up to get within the limits allowed by the forum. If anyone wants a copy of the original, message me you're email address.

Cheers

Capsur

 

Thank you, Caspur, for this valuable research.

 

May I take you up on your offer of the pdf?

 

Kind regards

 

Edited by ChessieCat
removed email and PMed member

1990: Started taking 200mg per day of SSRI (Sertraline)

April 2019: Tapered at a rate of 10% per week. This rate was recommended by Imperial College, London, Centre for Neuropsychopharmacology, as part of their study into psilocybin for major depressive disorder.

4 July 2019: First day with zero intake; no intake of Sertraline since.

 

2019

Sertraline: Jan 1 200mg; April 26 180mg; May 3 160mg; May 10 140mg; May 17 120mg; May 24 100mg; May 31 80mg; June 7 60mg; June 14 40mg; June 21 20mg; June 28 to July 4 10mg. July 5 0.00mg.

Sertraline reinstatement: 30 August 2019 1.0mg per day; 12 Sept 2019 1.25mg per day

Clopidogrel: 75mg per day - ongoing

6 Aug 2019: Co-codamol: max 60mg per dose, up to 4 times a day. Only a temporary measure until the pain in my hand is mended.

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  • 3 weeks later...
  • Moderator Emeritus

* NO LONGER ACTIVE on SA *

MISSION ACCOMPLISHED:  (6 year taper)      0mg Pristiq  on 13th November 2021

ADs since ~1992:  25+ years - 1 unknown, Prozac (muscle weakness), Zoloft; citalopram (pooped out) CTed (very sick for 2.5 wks a few months after); Pristiq:  50mg 2012, 100mg beg 2013 (Serotonin Toxicity)  Tapering from Oct 2015 - 13 Nov 2021   LAST DOSE 0.0025mg

Post 0 updates start here    My tapering program     My Intro (goes to tapering graph)

 VIDEO:   Antidepressant Withdrawal Syndrome and its Management

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  • 1 year later...
On 3/5/2019 at 10:50 PM, Henosis said:

Published:March 05, 2019 The Lancet DOI:https://doi.org/10.1016/S2215-0366(19)30032-X

Tapering of SSRI treatment to mitigate withdrawal symptoms

Mark Abie Horowitz, PhD

Prof David Taylor, PhD

 

Summary at https://www.thelancet.com/journals/lanpsy/article/PIIS2215-0366(19)30032-X/fulltext Full text requested.

 

All classes of drug that are prescribed to treat depression are associated with withdrawal syndromes. SSRI withdrawal syndrome occurs often and can be severe, and might compel patients to recommence their medication. Although the withdrawal syndrome can be differentiated from recurrence of the underlying disorder, it might also be mistaken for recurrence, leading to long-term unnecessary medication. Guidelines recommend short tapers, of between 2 weeks and 4 weeks, down to therapeutic minimum doses, or half-minimum doses, before complete cessation. Studies have shown that these tapers show minimal benefits over abrupt discontinuation, and are often not tolerated by patients. Tapers over a period of months and down to doses much lower than minimum therapeutic doses have shown greater success in reducing withdrawal symptoms. Other types of medication associated with withdrawal, such as benzodiazepenes, are tapered to reduce their biological effect at receptors by fixed amounts to minimise withdrawal symptoms. These dose reductions are done with exponential tapering programmes that reach very small doses. This method could have relevance for tapering of SSRIs. We examined the PET imaging data of serotonin transporter occupancy by SSRIs and found that hyperbolically reducing doses of SSRIs reduces their effect on serotonin transporter inhibition in a linear manner. We therefore suggest that SSRIs should be tapered hyperbolically and slowly to doses much lower than those of therapeutic minimums, in line with tapering regimens for other medications associated with withdrawal symptoms. Withdrawal symptoms will then be minimised.

How do I access the full text of this article without having to pay for it?  The links in Chessie's post above mine appear to be to correspondence responding to the article and not to the original article.  

 

 

2016-Aug-Prescribed 2 mg Ativan & 10 mg Ambien; Oct-c/o from 20 mg Lexapro to 60 mg Cymbalta; Nov-Dec-Tapered off 10 mg Ambien    

2017-Jan-Feb c/o from 1.75 mg Ativan to 13 mg Valium & begin daily liquid micro taper; May-taper Cymbalta 60 mg to 48 mg with severe withdrawals.  Begin 11 month Cymbalta hold.

2018-Jan 11 completed Valium taper; Apr-Resume Cymbalta taper.  Interval dose progress: Apr 43 mg; May 40 mg; Jul 35 mg; Sep 29 mg; Dec 21 mg; 

2019- Apr 14 mg; Jun 11 mg; Aug 9 mg; Oct 7 mg; Nov 6 mg

2020-Jan 5.2 mg; Feb 4.8 mg; Mar 4.3 mg; Apr 3.9 mg; May 3.5 mg; Jun 3.3 mg; Jul 2.9 mg; Aug 2.7 mg; 28 Sep 2.4 mg/12 beads; 25 Oct 2.2 mg/11 beads; 22 Nov 2.0 mg/10 beads; 20 Dec 1.8 mg/9 beads

2021- 17 Jan 1.6 mg/8 beads; 14 Feb 1.4 mg/7 beads; 18 Mar 1.2 mg/6 beads; 18 Apr 1.0 mg/5 beads; 16 May

0.8 mg/4 beads; 13 Jun 0.6 mg/3 beads; 11 Jul 0.5 mg/2 beads; 8 Aug .03 mg/1 bead; 5 Sep 0 mg.

Brutal, agonizing, slow 4.5 year Cymbalta taper completed as of 5 Sep 2021.  100% psych drug free.  

 

 

 

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On 9/2/2019 at 6:42 PM, ChessieCat said:

These links are to correspondence responding to Horowitz's Lancet article but not to the original article, itself.  How do we access the full original article without having to pay for it? 

 

2016-Aug-Prescribed 2 mg Ativan & 10 mg Ambien; Oct-c/o from 20 mg Lexapro to 60 mg Cymbalta; Nov-Dec-Tapered off 10 mg Ambien    

2017-Jan-Feb c/o from 1.75 mg Ativan to 13 mg Valium & begin daily liquid micro taper; May-taper Cymbalta 60 mg to 48 mg with severe withdrawals.  Begin 11 month Cymbalta hold.

2018-Jan 11 completed Valium taper; Apr-Resume Cymbalta taper.  Interval dose progress: Apr 43 mg; May 40 mg; Jul 35 mg; Sep 29 mg; Dec 21 mg; 

2019- Apr 14 mg; Jun 11 mg; Aug 9 mg; Oct 7 mg; Nov 6 mg

2020-Jan 5.2 mg; Feb 4.8 mg; Mar 4.3 mg; Apr 3.9 mg; May 3.5 mg; Jun 3.3 mg; Jul 2.9 mg; Aug 2.7 mg; 28 Sep 2.4 mg/12 beads; 25 Oct 2.2 mg/11 beads; 22 Nov 2.0 mg/10 beads; 20 Dec 1.8 mg/9 beads

2021- 17 Jan 1.6 mg/8 beads; 14 Feb 1.4 mg/7 beads; 18 Mar 1.2 mg/6 beads; 18 Apr 1.0 mg/5 beads; 16 May

0.8 mg/4 beads; 13 Jun 0.6 mg/3 beads; 11 Jul 0.5 mg/2 beads; 8 Aug .03 mg/1 bead; 5 Sep 0 mg.

Brutal, agonizing, slow 4.5 year Cymbalta taper completed as of 5 Sep 2021.  100% psych drug free.  

 

 

 

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30 minutes ago, gardenlady said:

These links are to correspondence responding to Horowitz's Lancet article but not to the original article, itself.  How do we access the full original article without having to pay for it? 

 

Hi GardenLady,

Your best bet for getting access to papers is via Sci-Hub. https://sci-hub.st/

Sci Hub urls change so if this one stops working just search online for a working one.

Then you need the doi number of the paper you want - this is the doi for the Horowitz paper 10.1016/S2215-0366(19)30032-X

Got to Sci Hub and paste it into the search field. If the paper is available via this route it will give you access to a pdf

 

This is the Sci Hub link for the Horowitz paper you want:

https://sci-hub.st/10.1016/S2215-0366(19)30032-X 

 

You have 90% chance that Sci Hub will provide most papers for you.

Cheers

Caspur

2011 - started Venlafaxine (again) at 75mg Raised to 150 mg at some point - unsure of dates. Reduced back down to 75 mg. Doctor advised this would be a lifetime, maintenance dose

2017 - Side effects now intolerable. Started taper from June 15th - 5% dose reduction steps (two 12 hourly doses).

2017 - October 20th - took last dose of Venlafaxine - 4 mg. Debilitating symptoms followed.

2017/18 - diazepam - 8mg/day for 1 month - 7 week taper Feb 2018

2017/18 - duloxetine - max 90mg - now stopped

2018 - Feb 25mg quetiapine, increased to 50mg.

2018 - March/April - increased venlafaxine slowly (10mg steps) to 75 mg/day. Recovery from withdrawal followed.

2018 - July 13 - stopped quetiapine after 2 month taper. Late July - had to reinstate quetiapine due to intolerable withdrawal. Now tapering from 25mg

2019 - June - stopped quetiapine after 10 month taper. Mild insomnia only symptom.

2021 - June - venlafaxine approx 6.0 mg see Taper history details

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4 minutes ago, Caspur said:

 

Hi GardenLady,

Your best bet for getting access to papers is via Sci-Hub. https://sci-hub.st/

Sci Hub urls change so if this one stops working just search online for a working one.

Then you need the doi number of the paper you want - this is the doi for the Horowitz paper 10.1016/S2215-0366(19)30032-X

Got to Sci Hub and paste it into the search field. If the paper is available via this route it will give you access to a pdf

 

This is the Sci Hub link for the Horowitz paper you want:

https://sci-hub.st/10.1016/S2215-0366(19)30032-X

 

You have 90% chance that Sci Hub will provide most papers for you.

Cheers

Caspur

Wow, thanks, Caspur!!!  This is great....works like magic!

 

2016-Aug-Prescribed 2 mg Ativan & 10 mg Ambien; Oct-c/o from 20 mg Lexapro to 60 mg Cymbalta; Nov-Dec-Tapered off 10 mg Ambien    

2017-Jan-Feb c/o from 1.75 mg Ativan to 13 mg Valium & begin daily liquid micro taper; May-taper Cymbalta 60 mg to 48 mg with severe withdrawals.  Begin 11 month Cymbalta hold.

2018-Jan 11 completed Valium taper; Apr-Resume Cymbalta taper.  Interval dose progress: Apr 43 mg; May 40 mg; Jul 35 mg; Sep 29 mg; Dec 21 mg; 

2019- Apr 14 mg; Jun 11 mg; Aug 9 mg; Oct 7 mg; Nov 6 mg

2020-Jan 5.2 mg; Feb 4.8 mg; Mar 4.3 mg; Apr 3.9 mg; May 3.5 mg; Jun 3.3 mg; Jul 2.9 mg; Aug 2.7 mg; 28 Sep 2.4 mg/12 beads; 25 Oct 2.2 mg/11 beads; 22 Nov 2.0 mg/10 beads; 20 Dec 1.8 mg/9 beads

2021- 17 Jan 1.6 mg/8 beads; 14 Feb 1.4 mg/7 beads; 18 Mar 1.2 mg/6 beads; 18 Apr 1.0 mg/5 beads; 16 May

0.8 mg/4 beads; 13 Jun 0.6 mg/3 beads; 11 Jul 0.5 mg/2 beads; 8 Aug .03 mg/1 bead; 5 Sep 0 mg.

Brutal, agonizing, slow 4.5 year Cymbalta taper completed as of 5 Sep 2021.  100% psych drug free.  

 

 

 

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  • 7 months later...
On 3/6/2019 at 4:50 AM, Henosis said:

Published:March 05, 2019 The Lancet DOI:https://doi.org/10.1016/S2215-0366(19)30032-X

Tapering of SSRI treatment to mitigate withdrawal symptoms

Mark Abie Horowitz, PhD

Prof David Taylor, PhD

 

Summary at https://www.thelancet.com/journals/lanpsy/article/PIIS2215-0366(19)30032-X/fulltext Full text requested.

 

All classes of drug that are prescribed to treat depression are associated with withdrawal syndromes. SSRI withdrawal syndrome occurs often and can be severe, and might compel patients to recommence their medication. Although the withdrawal syndrome can be differentiated from recurrence of the underlying disorder, it might also be mistaken for recurrence, leading to long-term unnecessary medication. Guidelines recommend short tapers, of between 2 weeks and 4 weeks, down to therapeutic minimum doses, or half-minimum doses, before complete cessation. Studies have shown that these tapers show minimal benefits over abrupt discontinuation, and are often not tolerated by patients. Tapers over a period of months and down to doses much lower than minimum therapeutic doses have shown greater success in reducing withdrawal symptoms. Other types of medication associated with withdrawal, such as benzodiazepenes, are tapered to reduce their biological effect at receptors by fixed amounts to minimise withdrawal symptoms. These dose reductions are done with exponential tapering programmes that reach very small doses. This method could have relevance for tapering of SSRIs. We examined the PET imaging data of serotonin transporter occupancy by SSRIs and found that hyperbolically reducing doses of SSRIs reduces their effect on serotonin transporter inhibition in a linear manner. We therefore suggest that SSRIs should be tapered hyperbolically and slowly to doses much lower than those of therapeutic minimums, in line with tapering regimens for other medications associated with withdrawal symptoms. Withdrawal symptoms will then be minimised.

@Henosis

can I ask you why did you introduce 8mg Prozac when you had tapered down to 3mg Paxil? 
Reason I ask is that I am on 2.9mg Paxil having tapered from 20mg with lots of symptoms along they way.  Was it because the lower you got the more intolerable WD side affects? 
Thank you 

Nov 2018 Pregabalin 2x50 mg a day to help with Paxil WD. Aug 2019 2 x 25mg a day, April 2020 45mg, May 40mg, June 35mg, July 30mg, end July 25mg, Aug 24mg, June 2021 14mg, Jan 2022 14mg (2x7mg a day), Oct 10mg, Nov 5mg, December 25th 2022 0mg 🎈

 

Oct 2004 - Oct 2018 Paxil 20 mg, Nov 15mg, Dec 10mg,  Feb 2019 7.5mg crashed, Feb 8.5mg, Nov 8mg, March 2020 7.2mg, April 6.5mg, May 5.9mg, June 5.4mg, July 4.8mg, Dec 4.5mg, Jan 2021 4mg, Feb 3.6mg, March 3.2mg, April 2.9mg, Aug 2.7mg, Sept 2.4mg, Oct 2.2mg, Nov 2mg, Dec 1.8mg, Feb 2022 1.6mg, March 1.4mg, April 1.2mg, May 1.0mg, June 0.8mg, July 0.6mg, Aug 0.4mg, Sep 0.2mg, October 6th 2022 0mg  🎈

 

December 25th 2022 drug free 

 

these dates are approximate 

 

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  • 1 month later...
On 5/21/2021 at 1:13 AM, Longroadhome said:

@Henosis

can I ask you why did you introduce 8mg Prozac when you had tapered down to 3mg Paxil? 
Reason I ask is that I am on 2.9mg Paxil having tapered from 20mg with lots of symptoms along they way.  Was it because the lower you got the more intolerable WD side affects? 
Thank you 


I started to have panic attacks / strange anxiety/dissociation symptoms. At the same time, It started to become difficult to measure the dose and I wasn’t sure if inaccuracy was also exacerbating the symptoms.

 

Adding Prozac helped, but it did take away the endorphin/normal dopamine windows I would get after working out, etc. In any case, I was able to finish the Paxil taper because of it. 

Medication before problems: Took Paxil 60-100mg from 2003 to 2014 for OCD.
1) Last pill taken November 2014, horrendous withdrawal started six weeks later.

2) Re-instated successfully @ 20mg May 2015, but accompanied by severe anhedonia, loss of emotion, apathy, and fatigue

3) Switched to Prozac, Viibyrd, Zoloft, Nefazadone, Cymbalta, Nardil in attempt at abating WD symptoms while not re-introducing anhedonia. Each one either failed to relieve WD or brought back anhedonia. So re-stabilized on Paxil at 15mg

4) Tapered down to 7.5mg as of October 2016. More energy, anhedonia/loss of emotions remains apart from short windows.

5) May 2017 - down to 3.5mg of Paxil (no other meds)
6) Early 2018 - added 8mg of Prozac
7) January 2019 - down to 1.05 Paxil / 5mg Prozac and continuing

8) October 2019 - down to 0.2mg Paxil / 3mg Prozac

9) November 2019 - down to 0.1mg Paxil / 3mg Prozac 

10) March 2020 - done with Paxil, 2.5mg Prozac

11) April 2021 - 0.03mg Prozac

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  • 1 year later...

Titled: Interesting Taylor and Horowitz taper recommends

 

I read the Taylor and Horowitz Lancet paper cited in the 'Why 10% Taper' thread. I was surprised to find them recommending a linear, 10% SERT occupancy reduction taper which is a substantially faster than the SA-style 10% hyperbolic dosage reduction taper. Their schedule works out to dosage reductions in the neighborhood of 40% per step (vs the 10% we follow).

 

In table 2 they illustrate a would-be Citalopram taper with a dosage schedule that goes 19mg, 9.1mg, 5.4mg, 3.4mg, 2.3mg, 1.5mg, 0.8mg, 0.37mg corresponding to a SERT occupancy reduction of 80%, 70%, 60%, etc.

 

In general, a Taylor/Horowitz taper requires about 8-10 steps vs about 40-50 steps for a SA taper. Conversely, an SA taper has SERT occupancy step reductions around 2-3% vs TH's 10% reductions. I know this is all new/inexact science, but I’m surprised at such a large discrepancy.

Edited by manymoretodays
added title, merged to paper referred to

- - - - - - past rx- - - - - - - - - - - - - - - -

Prozac 20mg [2015 - 2017]   |  9-12 month taper, no withdrawal syndrome

Wellbutrin XL 150mg [2015  - 2017]  |  9-12 month taper, no withdrawal syndrome

 

- - - - - - current rx- - - - - - - - - - - - - -

Wellbutrin XL 150mg [8/2022 - present]

Cymbalta 30mg  [7/2022 - 11/2022]   ....  Cymbalta taper (currently 2.3mg) [11/2022 - present]

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