Jump to content
Henosis

Horowitz, 2019 Tapering of SSRI treatment to mitigate withdrawal symptoms

Recommended Posts

Henosis

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.

Edited by Altostrata
Journals format

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 

Share this post


Link to post
Share on other sites
Henosis

“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 

Share this post


Link to post
Share on other sites
Altostrata

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.

Share this post


Link to post
Share on other sites
Caspur

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 does 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.

2020 - sept  - venlafaxine 17.1 mg.

 

Taper history details

Share this post


Link to post
Share on other sites
Caspur

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 does 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.

2020 - sept  - venlafaxine 17.1 mg.

 

Taper history details

Share this post


Link to post
Share on other sites
Caspur

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 does 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.

2020 - sept  - venlafaxine 17.1 mg.

 

Taper history details

Share this post


Link to post
Share on other sites
dcrmt

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.

Share this post


Link to post
Share on other sites
Kittygiggles

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/

 

Share this post


Link to post
Share on other sites
Lakelander82

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 

Share this post


Link to post
Share on other sites
Altostrata
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.

Share this post


Link to post
Share on other sites
Altostrata

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.

Share this post


Link to post
Share on other sites
Linus
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.

Share this post


Link to post
Share on other sites
Altostrata

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.

Share this post


Link to post
Share on other sites
TriD

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

Share this post


Link to post
Share on other sites
ChessieCat
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.


Being very patient.  I'll get there - slowly.  ETA mid 2021

ADs:  25 years - 1 unknown, Prozac (caused muscle weakness), Zoloft/sertraline; citalopram (pooped out) CTed (very sick for 2.5 wks a few months after)

Pristiq:  50mg 2012, 100mg beg 2013 (mild Serotonin Toxicity)

Began tapering Oct 2015  Current from 12 Sept 2020:  Pristiq 0.625 mg (compounded)

My tapering program

My Intro (goes to my tapering graph)

My website - includes my brief history + links to videos & information on the web

PLEASE NOTE:  I am not a medical professional.  I provide information and make suggestions.

Share this post


Link to post
Share on other sites
TriD
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

Share this post


Link to post
Share on other sites
Onmyway
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!


Aug  2000 - July 2003 (ct, 4-6 wk wd) , citalopram 20 mg ,  xanax prn, wellbutrin for a few months (don't remember dates), trazodone prn 

Dec 2004 - July 2018 citalopram 20 mg

Aug 2018 - citalopram 40 mg (self titrated up), occasionally did this in difficult times 

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

Feb 2019 0.25 xanax/day, then 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 2.0 mg (liquid), klonopin 0.25 once a week, April  14 , 2019 - citalopram 1.8 mg (liquid), May 8, 2019 - citalopram 1.6 mg (liquid),  July 27, 2019 - citalopram 1.5 mg (liquid),  August 15, 2019 - citalopram 1.35 (liquid)

 

 supplements:  melatonin 1 mg  

 

Share this post


Link to post
Share on other sites
Onmyway

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.


Aug  2000 - July 2003 (ct, 4-6 wk wd) , citalopram 20 mg ,  xanax prn, wellbutrin for a few months (don't remember dates), trazodone prn 

Dec 2004 - July 2018 citalopram 20 mg

Aug 2018 - citalopram 40 mg (self titrated up), occasionally did this in difficult times 

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

Feb 2019 0.25 xanax/day, then 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 2.0 mg (liquid), klonopin 0.25 once a week, April  14 , 2019 - citalopram 1.8 mg (liquid), May 8, 2019 - citalopram 1.6 mg (liquid),  July 27, 2019 - citalopram 1.5 mg (liquid),  August 15, 2019 - citalopram 1.35 (liquid)

 

 supplements:  melatonin 1 mg  

 

Share this post


Link to post
Share on other sites
Linus
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.

Share this post


Link to post
Share on other sites
Onmyway

 

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


Aug  2000 - July 2003 (ct, 4-6 wk wd) , citalopram 20 mg ,  xanax prn, wellbutrin for a few months (don't remember dates), trazodone prn 

Dec 2004 - July 2018 citalopram 20 mg

Aug 2018 - citalopram 40 mg (self titrated up), occasionally did this in difficult times 

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

Feb 2019 0.25 xanax/day, then 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 2.0 mg (liquid), klonopin 0.25 once a week, April  14 , 2019 - citalopram 1.8 mg (liquid), May 8, 2019 - citalopram 1.6 mg (liquid),  July 27, 2019 - citalopram 1.5 mg (liquid),  August 15, 2019 - citalopram 1.35 (liquid)

 

 supplements:  melatonin 1 mg  

 

Share this post


Link to post
Share on other sites
MissyE
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

Daily: 4g Omega 3 (3g epa & dha) 400IU vitamin E

2 puffs pulmicort inhaler.

This too shall pass.

 

Share this post


Link to post
Share on other sites
ChessieCat
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.


Being very patient.  I'll get there - slowly.  ETA mid 2021

ADs:  25 years - 1 unknown, Prozac (caused muscle weakness), Zoloft/sertraline; citalopram (pooped out) CTed (very sick for 2.5 wks a few months after)

Pristiq:  50mg 2012, 100mg beg 2013 (mild Serotonin Toxicity)

Began tapering Oct 2015  Current from 12 Sept 2020:  Pristiq 0.625 mg (compounded)

My tapering program

My Intro (goes to my tapering graph)

My website - includes my brief history + links to videos & information on the web

PLEASE NOTE:  I am not a medical professional.  I provide information and make suggestions.

Share this post


Link to post
Share on other sites
MissyE

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

Daily: 4g Omega 3 (3g epa & dha) 400IU vitamin E

2 puffs pulmicort inhaler.

This too shall pass.

 

Share this post


Link to post
Share on other sites
Onmyway

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."

 


Aug  2000 - July 2003 (ct, 4-6 wk wd) , citalopram 20 mg ,  xanax prn, wellbutrin for a few months (don't remember dates), trazodone prn 

Dec 2004 - July 2018 citalopram 20 mg

Aug 2018 - citalopram 40 mg (self titrated up), occasionally did this in difficult times 

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

Feb 2019 0.25 xanax/day, then 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 2.0 mg (liquid), klonopin 0.25 once a week, April  14 , 2019 - citalopram 1.8 mg (liquid), May 8, 2019 - citalopram 1.6 mg (liquid),  July 27, 2019 - citalopram 1.5 mg (liquid),  August 15, 2019 - citalopram 1.35 (liquid)

 

 supplements:  melatonin 1 mg  

 

Share this post


Link to post
Share on other sites
Linus
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.

Share this post


Link to post
Share on other sites
bubbles

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


My thread here at SA: https://www.survivingantidepressants.org/topic/1775-bubbles/page/14/

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 dropped from 100mg to 75mg, held for six months

2015 tapered to 50mg over several months, held for several months, some more drops

2016 Feb 35mg, 6 Mar 33mg, more drops (note big drop (calc error) & up to 25mg), more drops (about 2mg at a time)

2017 - more small drops, more long holds

2018 March at 11mg;  April 20 9mg; June 11 8.1mg; (July 10 7.7mg / July 18 7.3mg); ( Sept 2 7.2mg, Sept 5 7.1mg, Sept 9 7mg); 30 Sept 6.5mg, ? 6mg, 23 Nov 5.5mg) 19 Dec 5mg

2019 (micro drops over two weeks 24 Mar 4.9mg, 28 Mar 4.8mg, 31 Mar 4.7mg, 4 Apr 4.6mg, 7 Apr 4.5mg / 22 April 4.4mg, 26 April 4.3mg, 2 May 4.2mg, 5 May 4.1mg, 9 May 4mg), 3 Oct 3.9mg, (20 Oct 3.8mg, 27 Oct 3.7mg, 3 Nov 3.6mg), 24 Nov 3.5mg, 8 Dec 3.4mg, 15 Dec 3.3mg, 22 Dec 3.2mg

2020 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

Current Sertraline: July 24: 2 mg / Armour Thyroid / endless allergy meds, erg

Share this post


Link to post
Share on other sites
Redrag
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.

Share this post


Link to post
Share on other sites
AliveAgain

Is it possible that a pdf. of the original article in the Lancet from Horowitz and Taylor be posted here?

Share this post


Link to post
Share on other sites
ChessieCat

Being very patient.  I'll get there - slowly.  ETA mid 2021

ADs:  25 years - 1 unknown, Prozac (caused muscle weakness), Zoloft/sertraline; citalopram (pooped out) CTed (very sick for 2.5 wks a few months after)

Pristiq:  50mg 2012, 100mg beg 2013 (mild Serotonin Toxicity)

Began tapering Oct 2015  Current from 12 Sept 2020:  Pristiq 0.625 mg (compounded)

My tapering program

My Intro (goes to my tapering graph)

My website - includes my brief history + links to videos & information on the web

PLEASE NOTE:  I am not a medical professional.  I provide information and make suggestions.

Share this post


Link to post
Share on other sites

Create an account or sign in to comment

You need to be a member in order to leave a comment

Create an account

Sign up for a new account in our community. It's easy!

Register a new account

Sign in

Already have an account? Sign in here.

Sign In Now

×
×
  • Create New...

Important Information

Terms of Use Privacy Policy