ChrisD: advice please - sertraline, mirtazapine

[ChrisD]

I hope someone may be able to give me some advice. I am currently in an episode of Agitated Depression triggered by chronic pain & associated losses. I have had two previous episodes in 2014 & 2015/16. I eventually got well in about 6 months on each occasion & was taking 150mg Sertraline at the end of each episode. I'm not sure how much was to do with sertraline or whether the episodes just ran their course. I have been well for two years medication free but had a further breakdown in February this year. I started sertraline again & am currently taking 150mg I am also taking Mirtazapine 30mg as I wasn't sleeping. I am getting very concerned as I am not getting any better & am now taking two medications that I don't think are helping me. I feel really stuck as I am still very unwell. I live alone & am very isolated. My pain has increased as a result of the depressive episode.  I have been to a psychiatrist privately as it took too long to get help from NHS in UK & I was taking zoplicon for sleep which was only a short term solution. The psychiatrists only solutions are to keep increasing doses or swap so usual story. I tried mirtazapine at 45mg but couldn't sleep & fealt worse. When I went to see him originally he increased sertraline to 200mg after only being on 150mg for a few days & it was way too much. I have been taking 150mg sertraline for about 4 weeks now & 30mg mirtazapine a little longer probably 8 weeks. I started sertraline at 50mg in February. To be honest I am scared stiff to up the sertraline to 200mg. The psychiatrist has prescribed diazepam for breakthrough anxiety but I think I have already been taking this too often. I just don't know what to do. I am barely coping at the moment & live alone with just a few friends checking in on me. I don't know whether to cut my losses & taper off sertraline so that I am just on one drug go or go up to 200mg sertraline which does not sit well with me. The psychiatrist does not think I can get well without meds nor do my friends & want me to stay on them! I already feel worse if anything I am terribly agitated & anxious & have bad GI problems, constipation & mouth so dry I find it hard to speak sometimes. I am 66 by the way. If anyone has any help they can give me I would really appreciate it I feel incredibly alone at the moment.

Many Thanks

Chris

[SkyBlue]

2 hours ago, ChrisD said:

 If anyone has any help they can give me I would really appreciate it I feel incredibly alone at the moment.

Many Thanks

Chris

 

Hello, Chris, and welcome to SA.

 

I'm sorry to hear you're feeling so bad. Please know that you are definitely not alone. 

 

Please fill out a drug signature using these instructions: https://www.survivingantidepressants.org/topic/18343-please-put-your-withdrawal-history-in-your-signature/Most important are the most recent dosages and changes. That will give us a snapshot view of where you're at.

 

Many of us here can relate to being on one or more medications that aren't helping at all, that we want to come off of. It is definitely possible to do, and most people find the best results with tapering no more than 10% per month of the current dosage. We can get more into the details of that as we get your drug signature information.

 

Have you tried magnesium for the agitation? It can be very calming. https://www.survivingantidepressants.org/topic/15483-magnesium-natures-calcium-channel-blocker/

 

Please keep notes on paper about your daily symptom pattern.

Again, you are not alone. You will heal from this. Welcome.

Edited April 24, 2019 by SkyBlue
spaces

[ChrisD]

Hi Sky Blue. Sorry I'm not sure how to reply to you? I will update info you need.

[ChrisD]

Hello Sky Blue. Thanks for your reply. I have filled in all the details about meds now. Some friends picked me up to eat with them last night. I had a complete meltdown. I just do not know what to do. I have reached a more steady state taking the regimen of meds shown but am still very unwell. My concern is that If I consider withdrawing that I may become more ill. In January when I started taking meds again I had come to the conclusion that I needed to take them to get well as I had got well taking them before. I got worse very quickly in January starting again & am unsure how much was the depression worsening or the meds making things worse. It's so hard to know. Medication or not my life seems intolerable at the moment. I thought I had come to terms with my life with chronic pain & associated losses & was doing well for last 2 years. I now feel that falling back down the black hole of depression is my own fault, that I should have either stayed on meds or worked harder to come to terms with my life as it is now. It was such a shock to go down again & happened so quickly. Only I can resolve my problems I know but I feel utterly exhausted & do not know how to find enough fight to get out of this situation. I feel totally alone. My friends are supportive but cannot really understand.

[SkyBlue]

3 hours ago, ChrisD said:

My concern is that If I consider withdrawing that I may become more ill. In January when I started taking meds again I had come to the conclusion that I needed to take them to get well as I had got well taking them before. I got worse very quickly in January starting again & am unsure how much was the depression worsening or the meds making things worse. It's so hard to know. Medication or not my life seems intolerable at the moment.  It was such a shock to go down again & happened so quickly. Only I can resolve my problems I know but I feel utterly exhausted & do not know how to find enough fight to get out of this situation. I feel totally alone. My friends are supportive but cannot really understand.

 

Hi Chris,

 

I'm sorry you're feeling so bad. It sounds really tough. 

 

A lot of us can relate to feeling utterly exhausted with this situation. You are not alone, and here on SA you can find others in similar situations to help you through. You might read through others' forum threads here and comment on some; you will get to know some amazing people. I know I really rely on my SA friends when I'm in the kind of space that really only others on this journey can understand. 

 

I'm glad you were able to get out with friends. Even if they don't 100% understand our situation, it can help to be around people (even if it's just so we're not isolating as much). 

 

I don't know you personally, but I'd venture to say your feelings of depression aren't "your fault" at all. Speaking from my own experience, I found that in retrospect, Paxil only made me feel worse and worse. I do believe that depressive feelings and episodes naturally work themselves out over time (and strategies from us). Wish I had known that, but I know it now. 

 

It seems important to determine whether in January, the meds made things worse or not. Did things suddenly change for the worse or better, or stay about the same? I know you said it's hard to tell. 

 

Hang in there and please let us know how you're doing. 

 

Also, do you have a plan for safety if needed? Many people in this situation understandably find themselves feeling like they can't go on. There are Samaritans and other groups that can help, talk, etc., in crisis. You can make it through this. The people who have, are very very glad they did (and that includes me).

 

[ChrisD]

Thanks for your reply SkyBlue. No I guess blaming myself is not helpful. I'ts a long story but I had moved to French Alps to semi retire. I have always been very active, keen skier etc. I used to race cars in my youth. I ride motorcycles & this active person defined me. I had an episode of back pain that turned persistant & involved me having to return to UK. It completely destroyed me & was the start of the depression/anxiety episodes. I had been ok for two years & thought I had really come to terms with how my life had changed. Anyway I was triggered by a number of things relating to my losses & bang I ended up breaking down again. It seems so hard as I thought I was going to be ok. I am really scared this time I am so shaken. My anxiety is out of control. I had to sell my last car which I loved because I couldnt drive it & was in tears sounds stupid but it was symboloic & yet another loss. I went to have a look at a cheap car as a run around today & fealt completely destroyed by anxiety which is terryfying. I ended up taking diazepam I was so shaken but it doesnt work much now so clearly I'm getting tolerant to the 4mg dose that I have been taking for break through anxiety. So I know I need to be careful with it. The psychiatrist just tells me to take it but I think that is dangerous. I do not know what to do to be honest. The psychiatrist's last advice as I have not been improving is up sertraline to 200mg & if no response up mirtazapine to 45mg so both would then be at max dose. It feels like an impossible situation. From your experience & others is keeping upping the dose likely to ameliorate my anxiety or make it worse? When I  increased sertraline before It fealt too much & also I upped the mirtazapine to 45mg before & fealt horrible, I think I'm right in saying it becomes more active at higher dose. His only other option is to change the regimen.Thing is I am so unwell I am only just coping. If I go into Hospital I think that would be a very bad experience. When I am well I am very self sufficient good cook etc but at the moment I am really struggling. I talk to my nephew about how bad I feel because he understands. His Mum my Sister has been mentally ill all her life & was very difficult when I was very young. I had a bolt on the inside of my bedroom door! My Dad passed away when I was two so I guess these traumas effect the nervous system. I have had issues with anxiety all my life but medicated with high adrenelin job in Sales, motor racing etc. Anyway thats a bit of a ramble but hopefully gives a bit more back ground, if you or anyone can give any advice re my current situation I would so much appreciate it. I do call Samaritans sometimes & my nephew is non judgmental. I have a lot of lovely friends who care about me but there is little they can do really. Also they believe if I had remained on sertraline when I was unwell before that this wouldnt have happened. I'm not so sure there seems to be evidence that staying on them is not the answer. Again would appreciate others thoughts on that. Sorry this is so long!

Love to you all

Chris

[ChrisD]

Yes & you asked how I was in January before I started meds. I did go down vert quickly at work. I'm a salesman & couldn't deal with my customers. No hiding place in that situation. However I found in the past as well as this time the meds make things worse to start until a steady state is reached. Thing is a steady state is still feeling ill! Certainly where I am at present.

Best

Chris

[ChrisD]

PS I have bought some magnesium citrate powder!

[ChrisD]

I have been out today to look at buying a car as a run around. The side effects of the meds are not going to be something I will be able to tolerate. My mouth is dry so much its hard to talk, bad stomach, bloating indigestion, nausea & constipation. Tight feeling in my head & feels like my brain is pulsating! I was taking sertraline alone previously at 150mg & just about tolerated it for a while. If I want to cut down to one drug does anyone have any advice please?

Many Thanks

[SkyBlue]

Hi Chris, I'm going to check with the other moderators about your situation.

 

I'm hesitant to make a recommendation because if these started suddenly, could it be adverse reaction?

I don't know much about that.

 

Do you have a sense of which drug is causing the worst of the side effects?

It might be a good idea also to report these side effects to your doctor. They do seem pretty severe.

 

Glad you bought some magnesium.

Edited April 26, 2019 by SkyBlue
added text

[ChrisD]

Hi SkyBlue. I don't think it is a sudden adverse reaction per se, just that my body & I dont like the drugs. Because I have not been out very much, going out & doing anything much is stressful. The dry mouth is pretty constant. In the morning it is really bad. Also my mouth & gums are often sensative & sore. My stomach is upset most of the time I feel bloated after I eat particularly at night. I am also constipated & irregular bowel wise which I never am when I dont take meds. The strange feeling in my head was noticeable today when I was under stress of being out. I get a low grade tight headachy feeling often also. I have this kind of vibrating feeling in my head, like my nervous system is really off, which of course it is, alot of the time. Also my eyes feel sore. I'm sure Doctor & Psychiatrist will put it all down to my Depression & Anxiety & yes of course some will be. I had GI issues with sertraline when I took it before one of the reasons I couldn't keep taking it. The GI symptoms & dry mouth are much worse this time but I am taking two meds that have similar side effects. I am trying very hard to try & change my very negative thinking patterns using some of the tools I have used in the past. I'm not going to get through this with out working on this.

Any advice would be a great help

Thanks

Chris

[ChessieCat]

Hi Chris and welcome from me too,

 

Please use  Drug Interactions Checker for all the drugs you are currently taking and copy and paste the results here in your topic.

[ChrisD]

Hi ChessieCat,

Ok I have been on the drug checker site & copied & pasted for you. Apart from Sertraline & Mirtazapine the only other Medication I take is 10mg Enalapril maleate for Blood Pressure control. I have taken this for years. There doesn't appear to be any significant factors appart from Serotonin Syndrome. Thanks Chris.

Using sertraline together with mirtazapine can increase the risk of a rare but serious condition called the serotonin syndrome, which may include symptoms such as confusion, hallucination, seizure, extreme changes in blood pressure, increased heart rate, fever, excessive sweating, shivering or shaking, blurred vision, muscle spasm or stiffness, tremor, incoordination, stomach cramp, nausea, vomiting, and diarrhea. Severe cases may result in coma and even death. You should seek immediate medical attention if you experience these symptoms while taking the medications. Talk to your doctor if you have any questions or concerns. Your doctor may already be aware of the risks, but has determined that this is the best course of treatment for you and has taken appropriate precautions and is monitoring you closely for any potential complications. It is important to tell your doctor about all other medications you use, including vitamins and herbs. Do not stop using any medications without first talking to your doctor.

Enalapril and mirtazapine may have additive effects in lowering your blood pressure. You may experience headache, dizziness, lightheadedness, fainting, and/or changes in pulse or heart rate. These side effects are most likely to be seen at the beginning of treatment, following a dose increase, or when treatment is restarted after an interruption. Let your doctor know if you develop these symptoms and they do not go away after a few days or they become troublesome. Avoid driving or operating hazardous machinery until you know how the medications affect you, and use caution when getting up from a sitting or lying position. It is important to tell your doctor about all other medications you use, including vitamins and herbs. Do not stop using any medications without first talking to your doctor.

Alcohol can increase the nervous system side effects of mirtazapine such as dizziness, drowsiness, and difficulty concentrating. Some people may also experience impairment in thinking and judgment. You should avoid or limit the use of alcohol while being treated with mirtazapine. Do not use more than the recommended dose of mirtazapine, and avoid activities requiring mental alertness such as driving or operating hazardous machinery until you know how the medication affects you. Talk to your doctor or pharmacist if you have any questions or concerns.

It is recommended that if you are taking enalapril you should be advised to avoid moderately high or high potassium dietary intake. This can cause high levels of potassium in your blood. Do not use salt substitutes or potassium supplements while taking enalapril, unless your doctor has told you to.

The recommended maximum number of medicines in the 'antidepressants' category to be taken concurrently is usually one. Your list includes two medicines belonging to the 'antidepressants' category:

mirtazapine

sertraline

Note: The benefits of taking this combination of medicines may outweigh any risks associated with therapeutic duplication. This information does not take the place of talking to your doctor. Always check with your healthcare provider to determine if any adjustments to your medications are needed.

[ChrisD]

Sorry everyone I feel I'm being too neady at the moment but I'm pretty scared. I had to make a couple of phone calls to arrange some insurance this morning. something as simple as this gets me close to having an anxiety attack, & I'm at home! Clearly the anti depressants are not doing anything to help.  Can anyone advise from experience whether dose increase is likely to make matters better or worse? Also I have been taking diazepam on occasions but not regularly since February, could I be experiencing problems from this?

Thanks for any help

Chris

[Kostas]

Hi Chris, 

From what I am reading here and from the experienced mods comments, you never know how one will react in an updose! 

 

However in my case, being only on 20 mg citalopram max , I was able to stop it and reinstate on the original dose within a month from stopping, without major problems 3 times.

 

Then I did stabilized nicely in a couple of months. 

 

Finally I did a very slow tapering lasting almost 6 years, and I came off completely with only minor suffering. 

 

Now I am off the drug for 7 years and feeling fine. 

So although I can't offer you some solid advice, in my case reinstatement and uposing, worked OK. 

Please Take care 

 

[ChrisD]

Hi Kostas. Thankyou for your input. I am not reinstating as such. I was off the Sertaline for about 2 years & doing well. I have worked up to the 150mg dose that I was taking last time I was unwell plus I am taking Mirtazapine at 30mg. I am not feeling any better & to be honest not sure how much Sertraline helped last time. My difficulty is to know whether going up to 200mg on sertraline (highest dose) is going to help stabilise as this is what Psychiatrist wants.

Thanks

Chris

[SkyBlue]

45 minutes ago, ChrisD said:

My difficulty is to know whether going up to 200mg on sertraline (highest dose) is going to help stabilise as this is what Psychiatrist wants.

Thanks

Chris

 

Are your drug interactions concerning to you? I would definitely recommend speaking to your doctor about your symptoms. 

 

Here, we support people who are withdrawing from psych drugs; we don't advise for or against increasing dosages of medications. 

 

2 hours ago, ChrisD said:

Also I have been taking diazepam on occasions but not regularly since February, could I be experiencing problems from this?

We need to know all the psych drugs you are taking; please put this in your signature. How often before February?

[ChrisD]

Thanks SkyBlue. I have updated the signature. I have only been taking diazepam sparingly since February 2019 for breakthrough anxiety. I understand re dosage advice. I am due to see the Doctor next week. Unfortunately like many GP's I don't think she is very well informed re psychotropic meds. The psychiatrist has given his advice which is increase doses. It is likely he will say that my symptoms are due to my condition as this is his reaction previously when I have given a detailed description of my experience. 

Regards

Chris

[SkyBlue]

You're welcome. 

 

I'm glad it sounds like your doctors do or will know about your symptoms just in case there are adverse effects or interactions going on.

 

While you are deciding how to proceed, you might want to take a look at some information on the 10% tapering method: https://www.survivingantidepressants.org/topic/1024-why-taper-by-10-of-my-dosage/

 

Also: 

 

from the first post by Alto on that^ topic: 

On 5/4/2012 at 1:34 PM, Altostrata said:

Polypharmacy complicates tapering. Which drug to taper first?

Consider discussing the following considerations with your doctor.

 

You are having adverse effects from one or more of the drugs

• Put ALL the drugs you take in the Drug Interactions Checker at http://www.drugs.com/drug_interactions.html.
• Sometimes it's clear one drug is causing problems. You might consider tapering that drug first.

Any drug causing a serious life-threatening adverse effect should be discontinued as soon as possible. Talk to your doctor about this immediately.

 

[ChrisD]

Thanks for this information. I feel really stuffed to be honest. I'm now taking 2 medications that are not helping at current dose. I now have to make the decision as to whether follow the psychiatrists advice & up the dose of each in turn to see if it helps stabilise my depression/anxiety or if not trial another med to see if that stabilises. I'm not keen on doing that as it seems that they are all about as ineficient as each other, any views on this would be appreciated. Other option is to cut my losses & consider tapering off everything which will be a long job. My anxiety is really bad due to chronic pain & I want to get back to work which is looking really difficult. I get an anxiety attack doing the most basic things at the moment. I am wondering if the sertraline is not working this time (if it really worked before?)  because I have taken it twice before. I would have thought the mirtazapine would be more sedating, it does help me sleep but my anxiety is still really bad. Any input gratefully recieved.

Thanks

Chris

[ChrisD]

Does anyone have any views on following please. As mentioned I have chronic back pain, I have noticed since this epidode of depression started & that I simultaneously started taking meds my back pain is now much worse, also get stinging pain that extends round my torso, I also get like a burning pain in my legs at times & stomach pain & bloating after eating. Sort of Fibromalgia type symptoms that I have never experienced before. Could some of this be attributable to meds I wonde? I know chronic pain is exacerbated by depression/anxiety but it has never been as bad as it is right now. If anyone has experienced anything similar I would really appreciate your input.

Many Thanks

Chris

[ChrisD]

I have just had an email from my Psychiatrist re my meds:

 am sorry to hear that things are still difficult for you.

You should not be staying on any medication regimen if the benefits do not outweigh the problems.  If you are getting side effects which are intolerable for you then you should  stop.

The main reason for using sertraline was that it was effective for you last time and you tolerated it.

There will be an interaction between your anxiety disorder and side effects.

The variables to consider are the drug and the dose.

It may be helpful to have a period off medication to Re establish a baseline so you can then make an informed decision about further pharmacotherapy. That does not have to take a long time

Coming off your current regimen would be to stop mirtazapine and then reduce the sertraline to 100 mg for two weeks then 50 mg for two weeks and stop. Any discontinuation should resolve within two weeks.

I do think that you will need medication to treat your anxiety .

Alternative strategies would be stopping mirtazapine and switching from sertraline to venlafaxine, imipramine or pregabalin

A regular benzodiazepine could cover any potential deterioration during transition

You need regular support with this. 

From all the information on here this doesn't sound realistic. (This guy is an experienced Psychiatrist by the way with one of the major hospital groups in UK.) Please can anyone help!

[SkyBlue]

Hi Chris,

 

There are a few things that need to be decided, and really only you can decide them.

I've posted info above about tapering more than one drug; info at tapering at 10%; and you have some drug interactions to consider. 

You also have the doctor's recommendation, and whether you are going to follow that.

 

Yes, it has been our experience that psych drug effects and withdrawal effects can cause or mimic any kind of symptom, including physical pain. We each individually have to kind of sort out--which is an actual problem, and which is caused by the drugs or withdrawal. 

 

I encourage you to continue reading on the site and post your thoughts about what you decide. We mainly offer support and information. We don't have a clear-cut option of what you should definitely do. Please keep us posted.

[ChrisD]

Hi SkyBlue. I appreciate your response. Yes I agree it is only me that can decide. My situation in reality is pretty stark. I live alone and am very isolated. I have been to see my therapist today & we talked things through. Our society is such that it can be very easy to be marginalised & lonliness is very bad for anyone, let alone anyone with health problems. I don't say that in any way to say poor me, but it is a fact I'm 66 have always been self sufficient, active, gregarious  until my circumstances changed with Chronic Pain & depression through the many & ongoing losses. Yes I have friends but whilst they care about me I can't expect them to do more. I know they will not be supportive of me if I come off the drugs. I will keep you posted & appreciate the help & support you have given.

Warm Wishes

Chris 

[ChrisD]

Hello All,

Does anyone have experience of using Taperingstrip? I am considering using them for tapering off completely from 100mg sertraline. I have been reducing from 150mg starting at 125mg for 2 weeks by cutting 50mg pill (greater than 10 % but without any new issues.They have not worked in combination with 30mg mirtazapine so I am tapering sertraline first to see how I go). Also any opinion on the timeline for reduction would be appreciated, the kits are available in 112, 84,56 day options. I have been taking sertraline since 21/01/2019 on this occasion.

Best Wishes

Chris

[ChrisD]

Good Morning,

I have succesfully reduced my sertraline dose to 75mg by cutting tablets. I am still taking 30mg Mirtazapine at night. I certainly have not fealt any worse by reducing sertraline thus far. I am gradually making improvements to my health by my own efforts; therapy weekly, mindfulness practice, starting qigong pratice, returning to work slowly, learning to play guitar, painting.

I find I feel bad in the morning; not rested, fatigued still tired. I tend to have broken nights sleep and have vivid and often unpleasant dreams. I have a feeling this may be the mirtazapine but hard to tell. Also as previously mentioned I have a chronic pain condition & I am wondering if the mirtazapine may be contributing to this. I know the accepted reduction protocol is to reduce the most activating drug first if you are taking more than one drug & this has been my plan. However I would be grateful if anyone is able to advise re experience of mirtazapine & if it would be a bad idea to reduce this before completely coming off sertraline. I am remaing very cautious in my reduction despite the fact that I feel the medication hasen't helped me & am working hard to do all I can to support myself in recovery. I am also taking fish oil, magnesium citrate & vitamin B12. I also have an Alpha stim CES device that I am using.

My very best wishes to everyone in their recovery.

Kindest Regards

Chris