JandD: weeks on sertraline - extreme head pressure and suicide thoughts

[concerned]

I'm happy that your wife has not experienced major withdrawal symptoms with her past reductions! It is heartwarming to know that she has been able to laugh for the past two weeks. I am sure there is more healing ahead.

 

As far as antioxidants go, a number have been investigated for drug-induced movement disorders. I have gathered that their use in humans show mixed efficacy, though animal models are more promising. This difference may be because human trials initiated antioxidant therapy after symptoms had already appeared, whereas many animal studies started treatment at the onset of neuroleptic use. Prevention here seems to be the key. Other than NAC, I have come across studies using melatonin (among many others). I hope this helps, best wishes!

[Altostrata]

On 12/5/2022 at 12:04 PM, Altostrata said:

It's very common that women will have worse withdrawal symptoms during withdrawal.

 

 

Sorry! I meant that women often have worse withdrawal symptoms at times in their menstrual cycle.

[JandD]

Thank you for the previous good / kind comments!
Again just a short update and questions:

Current status:

• We have been holding 9mg Olanzapine since 35 days now to give my wifes body and nervous system time to adapt to the (microtaper) reduction.
• The last 18 days after the end of the normal menstrual cycle were actually quite good so far (almost no fear or dark thoughts) and we have our normal everyday life (my wife does not work).

• I have noticed a few unconscious movements of my wife's tongue. Lightly pressing against her cheeks and sometimes partially sticking out her tongue. She doesn't make other unconscious movements. But this worries me and I have asked her about it. It seems that this started a few weeks ago. Is this TD? My wife always takes Olanzapine and Mirtazapine in the evening around 11pm, about an hour before sleep. The unconscious movements of the tongue only seem to occur slightly towards evening. Possibly because the olanzapine level is lower then?

• As NAC seems to be helpful as an antioxidant against damage from olanzapine, she has been taking 600mg of NAC towards the evening for months. In addition, she has now been taking 200mg at midday for 10 days. However, we have not noticed any change.

 

Experiences:

• By holding the level, the sleep time has become a little longer (approx. 30 min per day)
• The reduction in autumn / winter seems to be a bit more difficult, as already written here.
• We have been microtapering so far, with small reductions every day and sometimes keeping the level for a few days. As written here, I have the feeling that it is important to take longer breaks without reduction in certain periods. Only after about 2 weeks does the body seem to make more extensive adjustments (e.g. reduction of receptors). If there are no breaks, something "unfinished" seems to build up, which seems to lead to more future severe withdrawal symptoms. The pause in the reduction therefore seems important, as the symptoms often appear with a time delay.
   

Thoughts / questions:

• How should we classify the unconscious tongue movements? Does this have an impact on the way we taper? 
• Is it advisable to shorten the holding period of the current dose for regeneration and to continue slowly with the reduction again in about 2 weeks? (to get to a lower level as quickly as possible because of TD) The reduction could be easier as we are then on holiday in the sun for a few weeks.
• Is a modification of Microtapering more in the direction of the Brassmonkey method (1st week 5%. 2nd week 5%, 3rd & 4th week hold during menstrual cycle and for recovery from nervous system) make sense? 

I am grateful for any kind of feedback.

 

[Altostrata]

8 hours ago, JandD said:

I have noticed a few unconscious movements of my wife's tongue. Lightly pressing against her cheeks and sometimes partially sticking out her tongue. She doesn't make other unconscious movements. But this worries me and I have asked her about it. It seems that this started a few weeks ago. Is this TD? My wife always takes Olanzapine and Mirtazapine in the evening around 11pm, about an hour before sleep. The unconscious movements of the tongue only seem to occur slightly towards evening. Possibly because the olanzapine level is lower then?

 

Yes, this is the drug-induced movement disorder associated with antipsychotics and antipsychotic withdrawal syndrome. It is possible that as she has lowered the olanzapine dosage, this arose from upregulated dopamine receptor supersensitivity, which causes the movement disorder. (Freeby60 has been tapering quetiapine using the tongue movements as a marker to adjust tapering speed.) This is an indication the taper has been too fast.

 

I would also be concerned about potential interaction of mirtazapine and olanzapine taken at the same time. (Interaction report requested in July.) It could be that mirtazapine, which has a relatively long half-life, slows metabolization of olanzapine, but when the prior night's mirtazapine wears off towards the evening, the olanzapine is metabolized faster and supersensitivity is exposed, causing the tongue movements.

 

However, you say you have been micro tapering (olanzapine? mirtazapine?) and this is a confounder. It may be that you are simply tapering too fast. We advise reductions at monthly intervals for the precise reason of permitting re-adaptation to the lower dose. An interval of 35 days is a normal interval, not a "hold".

 

If the tongue movements started after olanzapine was reduced to 9mg, that reduction might have been too great, and any successive microtapering has increased and prolonged the supersensitivity exposure. Suggest you not reduce olanzapine any further for another month and observe if the tongue movements relax. If they decrease, that indicates they arise from withdrawal-induced supersensitivity and you should consider reductions of perhaps 0.5mg at monthly intervals for a while.

[JandD]

Thank you for the valuable information! I will read up more on the subject of "metabolisation" and "timing of intake" and think about how to optimise this. We will keep the dose of Olanzapine stable at 9mg for one more month and observe whether the tongue movements relax. 

[JandD]

Again just a short update and questions:

Current status:

• We have been holding the 9mg Olanzapine level since 55 days now.
• Befor that we have been microtapering from 20mg Olanzapine to 9mg in the last 9 month. 
• The reductions in total per month were in mai 11,41%, june 11,66%, july 8,33%, august 11,74%, september 8,15%, october 8,2%, november 8,16% and december 0%.
• As recommended we have changed the times of the medication so that Olanzapine and Mirtazapine are no longer taken together. My wife now takes Olanzapine at 7pm in the evening and Mirtazapine four hours later at 11pm.

• As I have written my wife started to have a few unconscious movements of my wife's tongue around 10 weeks ago. Lightly pressing against her cheeks and sometimes partially sticking out her tongue. She doesn't make other unconscious movements. 

• As NAC seems to be helpful as an antioxidant against damage from olanzapine, she has been taking 600mg of NAC towards the evening for months. We have stopped the NAC arround as a test. 

 

Experiences:

• In the last few weeks (October/November) before keeping the 9mg level, she had more anxiety and dark thoughts, especially during her menstrual cycle. 

• After about 10 days of holding the 9mg level of Olanzapine, my wife's mood improved and she has had very little anxiety for the last five weeks. Sleep is also good at about 7.75 hours.

• However, the tongue movement continues unchanged. It now starts in the afternoon, but this is probably also related to the earlier intake of olanzapine.

• After "making love", the next day the tongue movements were less for that day.

• Two weeks ago my wife started recognizing after waking up in the morning, that she has the feeling that her hands and feet have fallen asleep / tingle slightly for a few minutes . A fortnight ago we stopped taking NAC daily.
   

Thoughts / questions:

• I was hoping that the movement of the tongue would decrease. By further pausing the dose and changing the time of intake.
• However the olanzapine, the dose level and the sensitivity towards this medication may also be the cause? 
• Therefore, we would like to take NAC again (as an antioxidant, which can probably at least reduce the likelihood of TD).
• Would want to do a 5% reduction fairly soon to reduce the dose and see if it has any effect on the movement of the tongue.

• If this does not lead to an increase, we would like to continue with the reduction (slightly adjusted BrassMonkey method).

• Another idea would be to also split the intake of olanzapine into two points in time. A small dose in the morning and the larger dose as now at 7 pm.

Thank you for any Feedback!
 

[Altostrata]

The tongue movements emerged after the September reduction, correct? This suggest the tongue movements were withdrawal symptoms. However, it is possible the remaining olanzapine is causing the tongue movements.

 

Many women here have reported withdrawal symptoms are worse at times in their menstrual cycle.

 

Good to hear some of your wife's symptoms have abated with a one month hiatus of tapering (December). Suggest she try holding at 9mg for another  month, see if the tongue movements reduce.

 

Please put ALL your wife's drugs in the Drug Interactions Checker https://www.drugs.com/drug_interactions.php

and copy and paste the results or a link to them in this topic.

 

[JandD]

Unfortunately, I have the feeling that the tongue movements do not come from a rapid reduction.
Despite keeping the dose at 9mg, it doesn't seem to be getting less or better. Possibly even a little more. All other reduction symptoms (sweating, sleep duration, anxiety) on the other hand are almost normal, even with the last menstrual cycle.

I first noticed the tongue movements on december 19th, a time when the dose had been held for 24 days, and the two months before that were not that fast either, with about 8% reduction each. My wife may have noticed the tounge movements earlier, when they may not have been so pronounced.

Today my wife also had another appointment with her psychiatrist. She found out that the prolactin levels from the mid-August blood test were elevated at "674mlU/L" (range 102 to 496). That's why he took blood again. Three months ago she was told that all the values were ok. A high prolactin level would also be indicated by the fact that my wife had irregular periods last time and she also says that she has the feeling that she is not ovulating. I read in an old research paper that all the women with TD also had elevated prolactin levels (https://pubmed.ncbi.nlm.nih.gov/6117204/).
 

As you can tell, I am really confused right now about what is the right way to go. I know how much experience and knowledge you have Altostrata, but my feeling is not to wait any longer and to reduce the Olanzapine dose as safely as possible with breaks, just to get to lower levels. I have fears that otherwise there may be a change of medication (possible difficulties) or the doctors may ask for a very quick reduction or the uncontrolled movements may continue to increase. 
 

--
Here is the Drug Interaction Report:
https://www.drugs.com/interactions-check.php?drug_list=1640-0,97-4252,1744-0

[Altostrata]

@JandD, it is possible that having been on olanzapine since March 2022 caused development of a common antipsychotic-induced movement disorder coincidentally in December, and that 9mg is contributing to this. If so, she should continue to reduce olanzapine at the rate she can best tolerate.

 

Elevated prolactin levels are another sign of adverse effect from olanzapine.

[JandD]

Just a short update

Current status:

• We have been tapering from 9mg (01/23) in small steps to 5mg now. My wife has more energy and feelings.
• We currently reduce 7.5-15% per month, depending on my wife's condition. The reduction is done in small steps over about 10 days. Then there is a break of 20 days so that the brain can adjust.
• The tongue movements are almost gone. 
• A blood test showed good values and prolactin also seems to be back in the normal range.
• We had a nice holiday break and have managed to live a mostly normal everyday life again. 
• Of course, there are also days with a little more brooding or anxiety, but these tend to be fewer and then usually only during the reduction phase or just before and during the menstrual phase.

 

Experiences:

• I find the information from the Walsh Research Institute interesting. My wife benefits from B vitamins (B6), zinc, vitamin C, fish oil and magnesium. Vitamin E, grape seed and little gingko against side effects of Olanzapine. We no longer take NAC.
• It is good to have a certain time distance when taking the medication due to metabolisation. For us, 8pm Olanzapine, about 10:30pm Mirtazapine. Thanks for the good advice Altostrata.
   

Thoughts / questions:

• Currently none. We are gently planning to continue along the previous path to reduce olanzapine to 2.5mg. We would then hold this level for some time at the end of the year and then reduce mirtazapine from 30mg to about 10mg (less antidepressant effect, more sleep-assisting effect)

 

[Altostrata]

Good to hear!

[JandD]

Just a short update 

Current status:

• We have been holding Olanzapine at 3,7mg (from 15.07.23) for four month now and switched to tapering Mirtazapine.
• We have been tapering Mitazapine from 30mg (10.08.23) in small steps to 15mg now. 
• We reduced the Mirtazapine at arround 13,3 - 18,18% per month. The reduction is done in small steps over about 10 days. Then there is a break of 20 days so that the brain can adjust.
• The tongue movements are completly gone. 
• We have managed to live an almost normal everyday. 
• Now we would hold the Mirtazapine at 15mg and plan to slowly taper the Olanzapine to about 1mg. 

 

Experiences:

• My wife has more energy and feelings.
• Tapering with Mirtazapine seems to be easier. 
• When we reduced 5% for the first time and also switched to 1/2 liquid, my wife felt a bit dizzy and nauseous for a day. These were the only "major" signs of reduction.
• Sleep is somewhat more restless about 3-6 days after a smaller reduction and the mornings are a little more difficult.
• Overall, however, sleep has become deeper / more restful.
• The slight skin rash (very probably caused by mirtazapine and histamine) has almost disappeared with the reduction from 30mg to 15mg Mirtazapine.
• So it seems to be an advantage not to reduce one medication completely and then the other, but to maintain a certain "balance".
• The severe head pressure - presumably caused by the adverse reaction to Sertraline 2 years ago - has improved considerably. Perhaps also due to the reduction of Mirtazapine? 
   

Thoughts / questions:

• We are planning to continue along the previous path to slowly reduce the olanzapine now again.
• We are thinking about getting a sleep tracker (Oura ring) to make sleep tracking more accurate and less complicated.
• At the moment we are grateful for the good tapering and the significantly lower level of medication now, which has not caused any bigger problems so far due to the cautious approach. We would also like to encourage others that situations can change for the better, even if we know that we have not yet reached the goal.

 

[Altostrata]

What excellent news. Thank you.

[JandD]

A short update again 

Current status:

• We have been holding Olanzapine at 1,875mg (from 13.03.24) for one month now and switched to tapering Mirtazapine again.
• We live an almost normal everyday without major restrictions. Of course, there are still limitations in feelings and motivation, but this improves with lower levels of medication.

Experiences:

• The original plan was to reduce Olanzapine a little longer to about 1mg. However, we have the feeling that a slightly longer break is always beneficial after reaching a reduction of Olanzapine by half. Towards the end of the reduction of last month cycle there were a few days (4) with more brooding and anxiety, which did not exist at the beginning of the reduction.
• Both olanzapine and mirtazapine are dissolved in water and then reduced accordingly using a pipette. This is relatively simple and quick and gives the good feeling of reducing much more accurately than with a precision balance, which costs 20 - 50 EUR (we briefly tested three models).
• Omega3 capsules made from fish oil have caused my wife's legs to bruise slightly. That's why she no longer takes them.
• The use of a tracker (especially for sleep) is helpful and beneficial.

 

Thoughts / questions:

• There are no questions right now and the thoughts are similar to the last feedback: "At the moment we are grateful for the good tapering and the significantly lower level of medication now, which has not caused any bigger problems so far due to the cautious approach. We would also like to encourage others that situations can change for the better, even if we know that we have not yet reached the goal."