Jools44: badly managed reinstatement of mirtazapine

[Jools44]

Hi, 

 

After reading your guide to reinstatement guide when hit with withdrawals I realise that I've gone about it completely the wrong way. 

 

I've reinstated at far too higher dose and then dropped far too quickly. 

 

I have been on 22.5 mg of mirtazepine for 4 weeks now but reinstatement has not worked properly and I am suffering with crippling insomnia, electric-current like tinnitus, hyperacusis and cognitive issues (poor concentration etc). 

 

I am at a complete loss at what to do now. Do I hold this dose and hope things stabilise or do I start a slow taper but risk causing more destabilisation to my already traumatised CNS? 

 

I'm about ot be Signed off work again as I can't function like this? 

 

Am I suffering from the kindling effect, if so what does that mean for me? 

 

Very worried about what damage I've done, I've handled this all wrong 😢

 

Edited November 7, 2021 by ChessieCat
added spacing

[Jools44]

Drug history 

 

4 years on 15 mg mirtazepine successfully tapered off.

Reinstated on 3.75mg - stayed on that for 4 years.

Stopped working at 3.75mg, attempted to discontinue the drug but after several weeks of crippling insomnia reinstated, stabilising at 22.5mg.

Stayed at 22.5mg for 12 months and then initiated slow liquid taper over 12 months.

Sept 2021 at 7.5mg hit very bad withdrawals - insomnia, headache, very bad anxiety., anorexia, tachycardia.

Panicked and reinstated at 30mg. Stayed at this dose for 3 weeks but didn't feel right and dropped down to 22.5mg.

Went in to full withdrawals again and am now left with crippling insomnia, electric tinnitus, hyoperacusis, extreme fatigue, cognitive issues.

 

Edited November 7, 2021 by ChessieCat
removed quote, resized font, added spacing

[Kiasofia]

Hello @Jools44

You have posted in the right place, sorry for the delay. I'm not sure what to advise you on this and will therefore confer with the other moderators and get you an answer as soon as possible. Until you hear back from us, do not make any changes and do not add inn another AD or anything else.

 

Is mirtazapine the only drug you are taking?

 

What date did you start 30 mg?

What date did you start 22.5mg?

 

To help us better advise you, can you please create a signature with all of the drugs that you are taking and have been taking in the last couple of years. 

How to List Drug History in Signature

 

I’m glad you found us, we’re here to support you!

[Jools44]

@Kiasofia thanks so much for you reply.

With regards to dosages I went from 7.5mg to 30mg on the 13th September. Stayed on that dose for 3 weeks. Initially felt better but then started to feel "odd" so dropped to 22.5mg. I don't know why I did that big a drop, I was just in a state of panic and don't find the GP's much help so tend not to turn to them. Went in to full withdrawals for 5 days. 

I've been on 22.5mg now for 5 weeks but my nervous system is not happy. The hyperacusis is really getting me down. 

[Kiasofia]

Can you explain what you mean by " feeling odd" when you were on 30 mg?

 

Do you take your dose once a day?

 

Do you take it the same time(s) every day? When?

 

Do you take any vitamins, supplements? What about alcohol, caffeine, nicotine, other mind altering substances?

 

How has your sleep been the last few days?

 

You say "full withdrawals for 5 days". Is it less intense now than it was?

 

What would be very helpful is if you start a daily symptoms journal that includes when you take Mirtazapin or anything else, symptoms you are having and the time and post daily updates here

 

Example template:

 

6 a.m. Woke with anxiety
8 a.m. Took 2.5mg Lexapro
10 a.m. Stomach is upset
10:30 a.m. Ate breakfast
11:35 a.m. Got a headache, lasted one hour
12:35 p.m. Ate lunch
4 p.m. Feel a bit better
5 p.m. Took 2.5mg Lexapro
6 p.m. Ate dinner
9:20 p.m. Headache
10:00 p.m. Took 50mg Seroquel
10:20 p.m. Feeling dizzy
10:30 p.m. Fell asleep
2:30 a.m. Woke, took 3mg Ambien (NOT "took 1/2 tablet Ambien")
2:45 a.m. Fell asleep
4:30 a.m. Woke but got back to sleep

6 a.m. Woke with anxiety (but less than yesterday)

 

Also see Dr. Joseph Glenmullen's withdrawal symptom checklist Read this to identify withdrawal symptoms.

 

Thank you for your patience as we try to determine the best advise to give.

[Jools44]

15 minutes ago, Kiasofia said:

Can you explain what you mean by " feeling odd" when you were on 30 mg?

 

Do you take your dose once a day?

 

Do you take it the same time(s) every day? When?

 

Do you take any vitamins, supplements? What about alcohol, caffeine, nicotine, other mind altering substances?

 

How has your sleep been the last few days?

 

You say "full withdrawals for 5 days". Is it less intense now than it was?

 

What would be very helpful is if you start a daily symptoms journal that includes when you take Mirtazapin or anything else, symptoms you are having and the time and post daily updates here

 

Example template:

 

6 a.m. Woke with anxiety
8 a.m. Took 2.5mg Lexapro
10 a.m. Stomach is upset
10:30 a.m. Ate breakfast
11:35 a.m. Got a headache, lasted one hour
12:35 p.m. Ate lunch
4 p.m. Feel a bit better
5 p.m. Took 2.5mg Lexapro
6 p.m. Ate dinner
9:20 p.m. Headache
10:00 p.m. Took 50mg Seroquel
10:20 p.m. Feeling dizzy
10:30 p.m. Fell asleep
2:30 a.m. Woke, took 3mg Ambien (NOT "took 1/2 tablet Ambien")
2:45 a.m. Fell asleep
4:30 a.m. Woke but got back to sleep

6 a.m. Woke with anxiety (but less than yesterday)

 

Also see Dr. Joseph Glenmullen's withdrawal symptom checklist Read this to identify withdrawal symptoms.

 

Thank you for your patience as we try to determine the best advise to give.

@Kiasofia

When I say odd, I felt like I had energy to do stuff but I felt blank, restless and couldn't sleep more than a few hours. 

 

I take mirtazepine once a day at night when I go to bed. 

I have just started taking magnesium to try and help with sleep. I take that a few hours before bedtime. I also take b12 in the morning. 

 

Currently off caffeine and alcohol, don't smoke. 

 

The withdrawal symptoms from the drop from 30 to 22.5mg have improved and I think they are slowly improving every day, although it's not linear. There are lots of tears some days and still feel quite numb (can't laugh or joke, just feeling no joy). 

 

My sleep has improved from what it was. I am getting about 4, maybe 5 hours a night currently but going from the dark circles under my eyes it's not great quality sleep.

 

I was using zopiclone at one point as my sleep was so bad but that made my tinnitus worse so I've dropped that completely as of 5 days ago. 

 

My psychiatrist recommended promethazine which I was reluctant to take and after taking 25mg one night)(Friday) and feeling shocking the next day I have not continued with that either. 

 

I have recently started using oestrogen gel (hrt) as of 7 days ago. I haven't started the progesterone yet as I didn't want to start it all at once. 

 

One thing I have noticed that is new is that upon waking I get these very odd body vibrations that are quite unnerving and not very comfortable. I'm not sure they're the brain zaps people speak off, I'd describe them more as possible adrenaline floods. 

 

I will do a daily diary if that is helpful and thank you for your help. 

[Jools44]

3 minutes ago, Jools44 said:

@Kiasofia

When I say odd, I felt like I had energy to do stuff but I felt blank, restless and couldn't sleep more than a few hours. 

 

I take mirtazepine once a day at night when I go to bed. 

I have just started taking magnesium to try and help with sleep. I take that a few hours before bedtime. I also take b12 in the morning. 

 

Currently off caffeine and alcohol, don't smoke. 

 

The withdrawal symptoms from the drop from 30 to 22.5mg have improved and I think they are slowly improving every day, although it's not linear. There are lots of tears some days and still feel quite numb (can't laugh or joke, just feeling no joy). 

 

My sleep has improved from what it was. I am getting about 4, maybe 5 hours a night currently but going from the dark circles under my eyes it's not great quality sleep.

 

I was using zopiclone at one point as my sleep was so bad but that made my tinnitus worse so I've dropped that completely as of 5 days ago. 

 

My psychiatrist recommended promethazine which I was reluctant to take and after taking 25mg one night)(Friday) and feeling shocking the next day I have not continued with that either. 

 

I have recently started using oestrogen gel (hrt) as of 7 days ago. I haven't started the progesterone yet as I didn't want to start it all at once. 

 

One thing I have noticed that is new is that upon waking I get these very odd body vibrations that are quite unnerving and not very comfortable. I'm not sure they're the brain zaps people speak off, I'd describe them more as possible adrenaline floods. 

 

I will do a daily diary if that is helpful and thank you for your help. 

@KiasofiaOne thing I forgot to mention is my constantly raised heart rate. It's running at about 90bpm most of the day, I think its part of the reason I'm so tired. I'm a pretty healthy individual apart from my now defunct brain so 90bpm is fast for me. I have wondered about going on propanolol but am so reluctant to add anything else to the mix. 

[Kiasofia]

Thanks for the info @Jools44

Please don't start any other medications until we have sorted out what to do with the Mirtazapin. So that the other moderators can get a quick overview without reading all the posts please create a signature with all of the drugs that you are taking and have been taking in the last couple of years, showing clearly when you started, quit, reinstated, raised the dose, and lowered the dose of Mirtazapin.

 

How to List Drug History in Signature

 

32 minutes ago, Jools44 said:

The withdrawal symptoms from the drop from 30 to 22.5mg have improved and I think they are slowly improving every day, although it's not linear. There are lots of tears some days and still feel quite numb (can't laugh or joke, just feeling no joy). 

This is a good sign. Are you familiar with this:

The Windows and Waves Pattern of Stabilization

[Jools44]

38 minutes ago, Kiasofia said:

Thanks for the info @Jools44

Please don't start any other medications until we have sorted out what to do with the Mirtazapin. So that the other moderators can get a quick overview without reading all the posts please create a signature with all of the drugs that you are taking and have been taking in the last couple of years, showing clearly when you started, quit, reinstated, raised the dose, and lowered the dose of Mirtazapin.

 

How to List Drug History in Signature

 

This is a good sign. Are you familiar with this:

The Windows and Waves Pattern of Stabilization

@Kiasofia i won't alter anything on my meds now until you guys have had a chance to review. Thank you for your responses so far, much appreciated. 

[Altostrata]

I agree with @Kiasofia, the improvement is a good sign.

 

6 hours ago, Jools44 said:

I've been on 22.5mg now for 5 weeks but my nervous system is not happy. The hyperacusis is really getting me down. 

 

When did the hyperacusis start? Has this changed over 5 weeks?

 

How do you feel after you take 22.5mg mirtazapine?

 

Your recent addition of estrogen may confuse your symptom pattern, as that drug also has adverse effects and other effects.

[Jools44]

5 hours ago, Altostrata said:

I agree with @Kiasofia, the improvement is a good sign.

 

 

When did the hyperacusis start? Has this changed over 5 weeks?

 

How do you feel after you take 22.5mg mirtazapine?

 

Your recent addition of estrogen may confuse your symptom pattern, as that drug also has adverse effects and other effects.

@Altostratai noticed some hyperacusis during the latter part of the taper before I crashed in September, but it was mild and didn't bother me that much. The real deterioration came when I reduced from 30mg to 22.5mg after reinstating. It's been persistent and very uncomfortable since then, so for about 4 weeks. I am seeing small improvements but I'm still very reactive to noise. The electric current like noise is still present but I would say that's diminished a little in volume too. 

 

I take the mirtazepine at bedtime and feel okay. It can take me a while to get to sleep and I'm only sleeping about 4 hours a night. 

 

I'm not sure what to do about the oestrogen now. In your experience are any of my symptoms likely to be linked to that? I haven't really noticed any major changes since starting it. 

 

I'm definitely getting the waves and windows affect. I did such a slow steady taper (although still not slow enough I realise now). I'm so cross at myself for cocking it all up. 

 

Thank you for your help. 

[Altostrata]

Do you feel any effect from the estrogen?

 

Do you have tinnitus -- a noise in your ears? Does this get worse at any particular times of day?

[Jools44]

@Altostrata yes I guess it's tinnitus although it feels like it's a noise in my brain not my ears. I think the volume is directly linked to the quality of my sleep, the better I sleep the less audible the tinnitus.

 

I think it's hard to say with the oestrogen. I was feeling quite anxious and low which has improved, but that may just be down to the AD settling down again (hopefully). I haven't noticed any negatives so far. 

 

Yesterday was a bad day but today has been better. 

 

I did develop a tremor in my left hand about a month before I crashed. This can happen with withdrawals can't it? The psychiatrist said it was a side effect from being on the drug for 10 years. Do you think this makes me a bad candidate for getting off this stuff? I'm so worried about attempting another withdrawal in the future given this experience. 

[Altostrata]

1 hour ago, Jools44 said:

I did develop a tremor in my left hand about a month before I crashed. This can happen with withdrawals can't it? The psychiatrist said it was a side effect from being on the drug for 10 years.

 

If you developed the tremor after reducing the drug, it's probably from withdrawal. Did you have the tremor while you were taking mirtazapine either time?

 

Prior withdrawal syndrome indicates you are vulnerable to withdrawal. But if you taper gradually, you will be able to go off.

[Jools44]

@Altostrata no I didn't have the tremor when I was on a full dose or during the majority of the taper. 

 

Once I'm feeling more stable, 

How long do you think I should stay on this current dose before attempting withdrawal again? 

 

I'm sleeping better, but now have that awful angry feeling for no reason that I remember from being on a full dose. There's just no peace with this drug. 

 

[Jools44]

@Altostratasorry for all the questions, but the prospect of being left with permanent loud tinnitus and/or hyperacusis is not a pleasant thought. Are these common disorders that occur during withdrawal, that generally improve during healing once off the drug altogether?

 

Thanks for your help. 

[Kiasofia]

 The easiest way to find things on the forum is to go to a search engine and type in survivingantidepressants.org then what you are searching for. (survivingantidepressants.org tinnitus)

 

https://www.survivingantidepressants.org/topic/6840-hearing-things-could-be-your-drugs/

https://www.survivingantidepressants.org/topic/1736-tinnitus-what-does-all-that-noise-mean/

 

Yes, these are common disorders and like all withdrawal symptoms they generally improve, but it is very individual how long it takes.

 

I would recommend feeling stable for minimum 4 weeks before tapering further, but holding for longer can be wise. So the central nervous system is ready for the task of tapering.

 

[Jools44]

@Kiasofia thank you so much for your reassurance. I'm keeping a diary now as ever day is different at the moment. 

 

@Altostrata do we know why antidepressants can't be stopped abruptly the same way other legal and illegal drugs can be when detoxing? There's so much support for people with alcohol, cocaine, benzo addictions and they can seemingly go through a 10 days detox and come out the other side relatively healthy (albeit not "cured" due to the addictive nature of the drug)? 

 

So many people seem to taper down to miniscule doses of Ad's and still struggle when they jump off, often reinstating because the withdrawals are so severe?

 

I long for the day when people prescribed ADs are offered the same level of support when they want to come off the meds. We're heading for an AD withdrawal epidemic with the ever increasing number being prescribed. Although by the looks of it we're already there, it all just flies under the radar of the medical profession through sheer ignorance on the prescribers part. 

 

If you're aware of any initiatives in the UK for supporting people like myself  I'd be very interested to know. 

[Kiasofia]

9 hours ago, Jools44 said:

do we know why antidepressants can't be stopped abruptly the same way other legal and illegal drugs can be when detoxing?

I think this post explains it well:

How Psychiatric Drugs Remodel Your Brain

9 hours ago, Jools44 said:

alcohol, cocaine, benzo addictions and they can seemingly go through a 10 days detox and come out the other side relatively healthy

I'm not sure how true this is though. At least not for benzos! Many horror stories of people being detoxed off benzos. I think, like with antidepressants, there are those who can quit easily and there are those who can't. So if your in the lucky group, then a detox center would work, but otherwise it does a lot of harm.

 

9 hours ago, Jools44 said:

I long for the day when people prescribed ADs are offered the same level of support when they want to come off the meds.

I think the main "challenge" is that many people can easily quit them. Those of us who cannot, are told it's because we have a chemical imbalance in need of permanent medicating. So until the narrative changes...

 

You might appreciate this BBC mini documentary: https://www.bbc.co.uk/programmes/p086fjk7

 

Here are two UK-based initiatives:

 

http://cepuk.org/

 

https://www.antidepressantrisks.org/

 

I highly recommend reading  Anatomy of an Epidemic by Robert Whitaker as well as A straight talking introduction to psychiatric drugs by Joanna Moncrieff to better understand these drugs and their effects. I have a hope they will be standard medical curriculum one day...

 

[Jools44]

@Kiasofiathanks so much for that. There are some pretty scary stories on the antidepressant risk site 😳

I do feel trapped on this drug. Every time I attempt to come off it just gets harder. I'm not even sure if I should try again, the fear of the unknown and lack of medical support is pretty daunting. 

[Kiasofia]

19 minutes ago, Jools44 said:

There are some pretty scary stories on the antidepressant risk site 😳

Yeah, don't spend too much time reading that! Just know there are initiatives and people are trying to spread the word.

 

You have managed to taper well previously, and I think if you go slow enough, and are ready to quickly reinstate a sligthly higher dose if withdrawal becomes bad, then there is hope. I'm also "stuck" at the moment and waiting for better days. You have been on this drug for 10 years so there is no need to rush getting off. Some choose to taper down as low as possible and remain on a low dose, rather than risk quitting. Personally, I've stopped calculating when I can get off lamictal, and will just take it one day at a time.

[Jools44]

@Kiasofia wise words 😊 the recently failed attempt probably would have gone better had I taken it slower, although it was by no means rapid. This time I'll be even more aware of any withdrawal symptoms and act sooner to hold or even increase slightly if needs be.

 

The tinnitus is still present, slightly less intrusive and the hyperacusis has improved but not resolved completely. Still hoping both will. Sleep isn't perfect but much improved thankfully. 

 

Thanks again for your support in what has been a difficult time. 

[Altostrata]

On 11/10/2021 at 4:52 AM, Jools44 said:

I'm sleeping better, but now have that awful angry feeling for no reason that I remember from being on a full dose.

 

How long have you been on a reinstatement? Please put the details in your signature.

 

No one can predict what will happen with the tinnitus. Hyperacusis probably will fade.

 

13 hours ago, Jools44 said:

 

@Altostrata do we know why antidepressants can't be stopped abruptly the same way other legal and illegal drugs can be when detoxing? There's so much support for people with alcohol, cocaine, benzo addictions and they can seemingly go through a 10 days detox and come out the other side relatively healthy (albeit not "cured" due to the addictive nature of the drug)? 

 

They may be "cured" by being off the drug, but they still get withdrawal symptoms from those fast tapers. Then, during "rehabilitation", they have post-acute withdrawal for years, same as with antidepressants.

[Jools44]

@Altostrata I never got off the drug but I've been on an increased dose for 2 months now (from 7.5mg up to 30mg for 3 weeks, then down to 22.5mg for the last 5 weeks).

 

If the tinnitus doesn't settle then I'll pursue TRT to see if that gives me some relief. I'll be relieved if the hyperacusis fades, as that's been very bothersome. 

[Altostrata]

How did the reduction to 22.5mg affect your hearing symptoms?

 

Very possible the estrogen has aided sleep.

[Jools44]

@Altostrata it was the sudden drop from 30 to 22.5mg that really kicked off the tinnitus and hyperacusis.

As of today my moods have stabilised and my sleep has really improved. If it wasn't for my hearing issues and the fatigue, I'd say I'm back to baseline now. 

I haven't added in the progesterone element to the HRT yet and I'm a bit torn as to whether to continue with it. I wasn't having any major menopausal symptoms but I was wondering if perimenopause was having some impact and was do desperate for relief. I'll certainly hold off adding the prog element for the time being. 

[Altostrata]

You may wish to take small amounts of magnesium throughout the day, as explained in our various topics.

[Jools44]

@Altostrata @Kiasofia

After some improvement I've gone downhill again. My sleeping improved although I was still having some poorer nights, but much better than it was, but after much self debate I decided to stop the oestrogen gel as I was concerned about adding the progesterone in as I wasn't 100% convinced I even needed HRT (although my mum went through it at the same age and suffered with depression). I had been on the oestrogen for just 2 weeks. 

I stopped the oestrogen on Friday of last week and since Tuesday night I can't sleep at all and am feeling very rotten again. 

It is so hard to know if this is a wave or as a result of stopping the oestrogen that may having been aiding my sleep and possibly mood.

If I restart the oestrogen then I will definitely have to commence the progesterone element too. 

 

I'm so miserable with the lack of sleep that I'm tempted to risk it, plus I've just gone back to work after 2 months off and have no paid sick leave left to take. 

 

The tinnitus and hyperacusis are still present although not as severe as before. The tinnitus gets me down as it's a constant reminder of the damage that has been done. I guess I have to find some way to reconcile myself to that but it's not easy. 

 

I live with my 77 year old mum at the moment who can't get her head around any of this and I feel awful for putting her through this stress but it's almost impossible for me to fake it for her as I'm in such a bad place. 

 

My boyfriend lives in Norway and I don't want to burden him with this either, plus I'm supposed to be going over to live there for 3 months in March. Hopefully I'll be feeling better by then but the way I'm feeling now it feels like a pipe dream.

 

I know you can't make any recommendations with the HRT and it's my call, but I've nobody else who understands the dilemma. I feel very alone in all this. I guess I'm just looking for some reassurance but I'm so tired of all this uncertainty already. I wouldn't mind so much if I'd actually got off the drug but to still be on it and suffering withdrawals is a bitter pill to swollow.

[Kiasofia]

I'm afraid I can't advise you on what to do. I'm very sorry to hear you've gone downhill. How have you been taking the magnesium? Altostrata recommended small doses throughout the day.

[Jools44]

@Kiasofia thanks for your reply. I am taking magnesium: one capsule in the morning and again in the evening.

 

I'm probably just being inpatient but the lack of sleep is the thing that gets me, and that's why I'm debating the HRT. So much more difficult to know what to do when you throw perimenopause in to the mix. 

[Greatful]

@Jools44

Hi , Welcome to SA.  I am so sorry that you are caught  in the middle of the ssri battle of pain, fear and dysfunction.

We are happy you found us.  Hopefully this will help stop the spiral to panic and poly drugging.

 

I think we all agree with you on how the medical field needs to get their head out of the sand.  They could plead ignorance to the horrors these drug inflict on us because there was no long term data, well now there is so ignorance is nota a excuse.  

They really don't know how many of us go through WD because most times it WD symptoms are considered relapse or a new mental illness appearing.  Studies are showing a higher %  of people experiencing WD at least 2 or more symptoms.

 

Be really careful  with adding anything for a quick fix.  Doc's want to start throwing what drugs they can at you to see what sticks.

You will be amazed when you read peoples thread the things they use ssri on.😖 

 

Holding still and letting some dust settle is  super hard......Your CNS is in a up roar and needs time to settle out.

Learn and educating yourself about these drugs and how they affect you, will help you feel like you are taking back some control of the situation.

http://Symptoms and self-care  on can help you connect with other members that are having the same WD symptoms as you

https://withdrawal.theinnercompass.org/  This is another web site with a ton of information 

 

Maybe this will help if you  haven't looked it up yet?

http://survivingantidepressants.org menopause

 

We are all in this together. One big happy family.  Happy to find some place that makes us feel connected to others in the same/or similar situations.  Reading success stories to be reassured that their brain can heal from these drugs.

 

Hang in there Jools☺️  The mods will come up with a plan

 

 

 

[Jools44]

@Greatfulthanks so much for your reply, having access to others experiences does help.

 

I'm a mirtazepine girl rather than ssri's. Not sure if that's a good thing or bad, doesn't feel too good at the moment! There is quite a lot of information around ssri withdrawal, but I guess it's a more commonly prescribed drug compared to mirt. 

 

I was thinking my improved sleep was down to the med kicking back in but now I'm thinking the oestrogen was playing a bigger factor. 

 

I will check out the menopause thread thank you 😊

 

 

 

[Altostrata]

You might want to add a half-dose of estrogen gel back in and see if that's what was helping.

 

Microdoses of estrogen do not quite progesterone complement. See 

 

Please use search in the Symptoms and Self-Care forum to see discussions about supplements, drugs, etc.

[Jools44]

@Altostrata can you suggest a daily dosage of magnesium based on peoples experiences here? They seem to differ wildly. I'm taking 240mg in two divided doses, and wondering if I should up when profound insomnia hits?. 

[Jools44]

@Altostrata in addition to the mg query above, I'm currently on 1mg of oestrogen gel daily applied in the evening, so would halving it be considered a micro dose? 

[Altostrata]

See https://survivingantidepressants.org/topic/15483-magnesium-natures-calcium-channel-blocker/

 

If 1mg estrogen gel is what's commonly prescribed, a lot of doctors would consider 0.5mg or 0.25mg a micro-dose.