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Dr. Bob is Robert Hsiung, MD,
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Posted by Dispossessed on March 1, 2014, at 21:29:16
In reply to Re: Sudden sensitivity to SSRIs/side effects?, posted by merpmerp on March 1, 2014, at 8:47:36
Thanks for the replies.
Merp - I certainly think that dopamine has something to do with my reaction to SSRIs - my lack of libido, poor attention, as well as the restlessness/akathisia appear to suggest this. I haven't tried bupropion - and I don't think the chances of being able to are great to be honest, as its not licensed in the UK for depression (only smoking cessation). I'm considering asking my GP for another referral to a psychiatrist, who may be likely to suggest it off-label. Did you ever try citalopram? It is more sedating than escitalopram (Lexapro) because it has higher affinity for histamine receptors - it may help with the restlessness perhaps.
Bleauberry - thanks for your post - Lyme disease is something that I've considered, and its possible as well. I've been hillwalking in areas where infected ticks potentially live. I'll mention it to my GP next time, but to be honest, he probably thinks that all my issues are psychiatric in nature. As its the NHS doctors prefer not to send people for blood tests because of the cost - and I'm not in a situation to afford to pay for private tests at the moment :(
Posted by g_g_g_unit on March 1, 2014, at 22:26:39
In reply to Re: Sudden sensitivity to SSRIs/side effects?, posted by merpmerp on March 1, 2014, at 8:47:36
I'm in the same position as you guys, merpmerp and Dispossessed. It's pretty frustrating.
I know Moclobemide is quite popular in the UK. There's an account of it treating tardive akathisia, so that might be an option, Dispossessed.
Posted by SLS on March 1, 2014, at 22:51:40
In reply to Sudden sensitivity to SSRIs/side effects?, posted by Dispossessed on February 27, 2014, at 15:38:13
How about trying Latuda (lurasidone)?
It is a weight-neutral, antipsychotic with antidepressant properties that takes advantage of serotonin 5-HT7 receptor blockade without reuptake inhibition. It is also a 5-HT1a partial agonist and a 5-HT2a antagonist. All of these things might come together to produce a clean antidepressant/anxiolytic response with just enough D2 antagonism to prevent hyperactivity in the prefrontal cortex (PFC).
http://www.ncbi.nlm.nih.gov/pubmed/20404009
- Scott
Posted by Dispossessed on March 2, 2014, at 9:22:02
In reply to Re: Sudden sensitivity to SSRIs/side effects? » Dispossessed, posted by SLS on March 1, 2014, at 22:51:40
I know that the akathisia will go away if I lower the dose or stop taking the medication, but then the intrusive thoughts/depression/anxiety come to take its place. I guess I could return to 5mg citalopram, which helped the anxiety/OCD without giving me akathisia, but at the cost of cognitive/visual problems. So its a double-edged sword.
Scott - thanks for the suggestion. It does seem that lurasidone lacks the cognitive side effects of the other APs, but it doesn't have approval in the UK yet. I'm also unsure as to what D2 receptor antagonism would do in terms of the akathisia/restlessness I get from the SSRIs - would it not worsen it?
Posted by SLS on March 2, 2014, at 10:05:08
In reply to Re: Sudden sensitivity to SSRIs/side effects?, posted by Dispossessed on March 2, 2014, at 9:22:02
> Scott - thanks for the suggestion. It does seem that lurasidone lacks the cognitive side effects of the other APs, but it doesn't have approval in the UK yet. I'm also unsure as to what D2 receptor antagonism would do in terms of the akathisia/restlessness I get from the SSRIs - would it not worsen it?
Akathisia is the result of D2 receptor blockade in the striatum. Latuda avoids this area. I hope this drug is made available to you soon. Stay away from SRIs (SSRIs + SNRIs) if you can. What non-SRI antidepressants have you tried? Have you tried Remeron (mirtazapine)? What about Solian (amisulpride)?
- Scott
Posted by Dispossessed on March 2, 2014, at 17:18:53
In reply to Re: Sudden sensitivity to SSRIs/side effects? » Dispossessed, posted by SLS on March 2, 2014, at 10:05:08
I've not tried mirtazapine - medication with antihistamine properties helps with anxiety/restlessness, at the cost of visual disturbances and cognitive dysfunction. I was on citalopram for 5 months and the visual/cognitive issues didn't fade at all. I've also tried low dose quetiapine, which had quite a sedating effect. I was told that the sedation would wear off eventually - but after just a day of taking it I was experiencing the same visual/cognitive issues that I experienced on citalopram.
Tell me more about amisulpride? I've heard of some people using it in low doses for depression.
Posted by phidippus on March 2, 2014, at 18:22:26
In reply to Re: Sudden sensitivity to SSRIs/side effects? » Dispossessed, posted by SLS on March 1, 2014, at 22:51:40
The problem with suggesting an antipsychotic without the benefit of an AD is worsening of OCD symptoms.
Eric
Posted by Dispossessed on March 2, 2014, at 18:40:06
In reply to Re: Sudden sensitivity to SSRIs/side effects? » SLS, posted by phidippus on March 2, 2014, at 18:22:26
Yes, I've heard that too. I can tolerate small doses of SSRIs - its just that at higher doses, I feel considerably more restless.
What kind of effects would antipsychotics have upon cognition in non-psychotic individuals out of interest? What about sexual function, motivation and concentration also (which I also have issues with?)
Posted by phidippus on March 2, 2014, at 19:03:54
In reply to Re: Sudden sensitivity to SSRIs/side effects?, posted by Dispossessed on February 28, 2014, at 20:51:44
> The akathisia is a feeling of mild panic/unease
coupled with an overwhelming desire to move my legs and armsThese could be just panic symptoms. When I have panic attacks I get the same kind of motor agitation.
The problem for you is SSRIs and Clomipramine are the most widely studied medications used to treat OCD. It is widely acknowledged that OCD is a result of a depletion of serotonin in key areas of the brain. It is also believed that excess dopamine is also involved in the pathonogenises of OCD-especially an excess of dopamine in the nucleus accumbens, which is the target of novel therapies for OCD namely deep brain stimulation. Other theories for the root cause of OCD involve glutamatergic models which have been studied-Topomax and Riluze, both anti-glutamatergic, have shown promise in the treatment of OCD, but these medications are always used alongside an SSRI.
If you want to treat your OCD appropriately, you need to take an SSRI to fix the serotonin imbalance in your brain. If you don't get enough response, you add a low dose AP. Then you add an anti-glutamatergic.
You need to find a way to treat the akathisia so you can take an AD or you're going to get nowhere.Eric
Posted by Dispossessed on March 2, 2014, at 19:11:42
In reply to Re: Sudden sensitivity to SSRIs/side effects? » Dispossessed, posted by phidippus on March 2, 2014, at 19:03:54
Thanks for your reply.
What would you recommend?
Once I get the feeling of panic under control I'm going to also consider CBT again. If CBT is the most successful way to treat OCD, does this mean that it is possible to rectify the serotonin imbalance without medication?
Posted by phidippus on March 2, 2014, at 19:13:05
In reply to Re: Sudden sensitivity to SSRIs/side effects?, posted by Dispossessed on March 2, 2014, at 18:40:06
You don't want to do an AP without an AD when treating OCD.
As for the cognitive effects of APs, it just depends on the AP. Latuda supposedly enhances cognition in schizophrenics.
APs have never effected my sexual function. Some have affected my motivation and some have effected my concentration.
Eric
Posted by merpmerp on March 2, 2014, at 19:27:42
In reply to Re: Sudden sensitivity to SSRIs/side effects?, posted by Dispossessed on March 1, 2014, at 21:29:16
I have tried citalopram, but only for like a couple of months. It was prescribed for a transitional period in my life. Since I was on it for such a short time, I can't remember how it was really. It might have helped a little.
I've been continuing to worsen, and have cut my 2.5 mg Lexapro to 1.25 mg daily. If I improve under this, I will contact my doctor and say I want off the Lex. The frequent diarrhea, intrusive violent thoughts, extreme muscle tension, crying spells are all back just like they were 4 years ago - and at that time, lowering the dosage was what fixed it. We will see.
Posted by phidippus on March 2, 2014, at 19:46:55
In reply to Re: Sudden sensitivity to SSRIs/side effects?, posted by Dispossessed on March 2, 2014, at 19:11:42
> What would you recommend?
I would recommend getting back on an SSRI and aggressively treating the akathisia. Beta-blockers are front line medication for akathisia, but a bunch of other medications have been shown effective:
Benzodiazapines
Opiates
Amantadine
Requip
Mirapex
Clonidine
Guanfacineand remember, OCD requires high doses of SSRIs to be treated adequately - Zoloft up to 400 mg, Prozac up to 60 mg, Lexapro 50 mg, etc.
>If CBT is the most successful way to treat OCD, does this mean that it is possible to rectify the serotonin imbalance without medication?
CBT is not the most succesful way to treat to treat OCD, though it can be helpful, along with DBT. The most successful teatment for OCD is ERP (exposure and ritual prevention). Its best to find a therapist who speciacalizes in OCD and ERP along with CBT therapies. ACT is very helpful as well.
Therapy will not rectify serotonin imbalances, but will provide you the tools to cope with OCD. ERP will affect brain circuits directly, lessening the brains response to perceived danger.
Eric
Posted by phidippus on March 2, 2014, at 19:50:11
In reply to Re: Sudden sensitivity to SSRIs/side effects?, posted by merpmerp on March 2, 2014, at 19:27:42
That's hardly a therapeutic dose. Most studies show OCD responds to high doses of SSRI treatment. What's the highest dose you have been on?
Eric
Posted by Dispossessed on March 2, 2014, at 20:06:25
In reply to Re: Sudden sensitivity to SSRIs/side effects? » Dispossessed, posted by phidippus on March 2, 2014, at 19:46:55
Thanks for that Eric - will try and arrange an appointment with a psychiatrist and throw a few suggestions his way.
I've tried propranolol at various dosages but have always found the side effects a bit hard to take (GI pain, epic gas) with no noticeable benefits. I was always told that it works well as a prn, but would I need to take it for a few days for it to have a noticeable effect on the akathisia? I know I should have given it a proper trial, but the GI issues are not particularly nice, particularly if spending a lot of time with close friends/loved ones!
I'm still on an SSRI (fluvoxamine) but still only at a low dose - 50mg. I'd like to increase but I know that the restlessness/jaw clenching are side effects of the drug and would only worsen.
You mentioned whether the akathisia was in fact anxiety symptoms - is there any way to tell whether it is that rather that akathisia? The SSRIs help reduce the intrusive thoughts and general anxiety I have, but make me feel more restless inside - when I'm in bed or at the computer I have to move my legs a lot or else I feel uncomfortable.
Posted by SLS on March 2, 2014, at 20:24:37
In reply to Re: Sudden sensitivity to SSRIs/side effects? » SLS, posted by phidippus on March 2, 2014, at 18:22:26
> The problem with suggesting an antipsychotic without the benefit of an AD is worsening of OCD symptoms.
I defer to your knowledge in this area.
Thanks.
- Scott
Posted by phidippus on March 3, 2014, at 14:56:46
In reply to Re: Sudden sensitivity to SSRIs/side effects?, posted by Dispossessed on March 2, 2014, at 20:06:25
> I've tried propranolol at various dosages
What dosages?
>would I need to take it for a few days for it to have a noticeable effect on the akathisia?
No, the effects should be readily apparent. In other words, you should have experienced rapid relief.
>I know I should have given it a proper trial,
but the GI issues are not particularly nice
perhaps another beta blocker would work instead. propanalol doesn't work for me either, but I've found pindolol helpful-espcially helpful for OCD as it is a 5ht1a agonist.> I'd like to increase but I know that the restlessness/jaw clenching are side effects of the drug and would only worsen.
That isn't necessarily true. Akathisia sometimes levels off at certain dosages.
> You mentioned whether the akathisia was in fact anxiety symptoms - is there any way to tell whether it is that rather that akathisia?
Taking a dose of benzodiazapine may unmask the anxiety.
> The SSRIs help reduce the intrusive thoughts
Remember, its not what the intrusive thoughts do to you, rather what you do with the intrusive thoughts.
you have no symptoms of restlessness when you're off the SSRI, correct?
The other thing you can try is a different antidepressant, one you haven't been on. I really like Viibryd and Brintellix.
Eric
Posted by Dispossessed on March 3, 2014, at 19:37:08
In reply to Re: Sudden sensitivity to SSRIs/side effects? » Dispossessed, posted by phidippus on March 3, 2014, at 14:56:46
> What dosages?
I've tried propranolol at 10, 20, 40mg instant, and 80mg extended release. Do you think that the lack of response could be evidence of physical anxiety symptoms?
> Taking a dose of benzodiazapine may unmask the anxiety.
I have around 5 2mg diazepam tablets I could take. Being in the UK, doctors are reluctant to give out benzodiazepines even for occasional use. When I had a spell of increased anxiety/intrusive thoughts I asked the GP for some and received a total of 14 2mg tablets. 4mg doesn't do anything to be honest, but that's the NHS. They're paranoid about benzo addiction after what happened in the 80s. I could take 10mg but I want to keep them in case I have a really, really bad day.
> you have no symptoms of restlessness when you're off the SSRI, correct?
I don't have the physical restlessness when off SSRIs, no. Certainly no restless legs/jaw clenching.
> The other thing you can try is a different antidepressant, one you haven't been on. I really like Viibryd and Brintellix.
I don't have that many options regarding antidepressants left. I could return to citalopram and be anxiety free but experience cognitive/visual issues. I haven't tried paroxetine but I'm unsure how long it would take for the anticholinergic side effects to fade. There was no change in visual/cognitive issues when I took sertraline, and I discontinued because it was seriously affecting my ability to study. Unfortunately the two drugs you mentioned are not available in the UK - the latter has been approved but will be released in the second half of 2014 (estimated).
> Remember, its not what the intrusive thoughts do to you, rather what you do with the intrusive thoughts.
I know what you mean. Though when I feel panicky and fear about losing control, the fear of acting on them is very real. I do have a book on OCD which told me to make a recording of the worst case scenario and play it back to myself on a loop - I made the recording but never listened to it on a daily basis because when the thoughts are particularly intrusive, its very easy to become demoralised.
Posted by SLS on March 3, 2014, at 20:31:02
In reply to Re: Sudden sensitivity to SSRIs/side effects?, posted by Dispossessed on March 3, 2014, at 19:37:08
I'm sorry to interrupt and ask a question that may have already been addressed, but how does your OCD manifest? Is it obsessions and ruminations only, or is there a compulsive counterpart including rituals?
I don't know. I am still looking at Latuda if you are ruminating and not experiencing compulsions. I have not researched this possibility well enough to recommend it, though. I would try the Brintellix first.
How did you respond to Luvox and clomipramine?
Perhaps Phiddipus can comment on combining Brintellix and nortriptyline. You would be adding NRI + 5-HT2a antagonism. Both drugs are metabolized by the same enzyme (CYP450 2D6), though. You might have to reduce the dosage of nortriptyline. With nortriptyline, you can get blood tests to use as a guideline for dosing. Adding the nortriptyline might help with depression, ruminations, and the anxiety that accompanies depression (as opposed to an anxiety disorder).
- Scott
Posted by LouisianaSportsman on March 3, 2014, at 21:02:20
In reply to Re: Sudden sensitivity to SSRIs/side effects? » Dispossessed, posted by SLS on March 3, 2014, at 20:31:02
I think the Latuda (lurasidone) would be an excellent choice to try next regardless of the "no AP without AD" philosophy you have, Eric. The only 5-ht activity that isn't good is the 5-HT2A antagonism which is balanced out by 5-HT1a partial agonism and perhaps the benefits of 5-HT7 antagonism. Lurasidone also has less of a cognitive imprint with its D2 receptor blockade pattern comparatively to other AAPs and actually has benefits (5-HT7).
It's too bad Viibyrd won't hit the market until the later part of 2014 and Brintillex is unknown. I am on my first day of Brintillex, Dispossessed, it's a shame the UK market is so far behind (via benzo prescribing too, I see).
Scott, BRAVO! for mentioning Luvox, a OCD SSRI posterboy and clomipramine, the heavy-hitter of OCD medications. The poster does not need to discredit trying these if at all possible.
<on combining Brintellix and nortriptyline
Scott, are you asking about combining Brintellix and nortriptyline for yourself because I'm not sure of augmenting nortriptyline for a patient suffering from OCD because why would you want to add 5-HT2A antagonism and clomipramine is so successful of a TCA for OCD due to selectivity to 5-HT over NE, unlike nortriptyline.
For yourself, I guess it turns it into a Cymbalta-lite by adding in the NE. The 5-HT2A antagonism from nortriptyline here may also make the 5-HT reuptake from vortioxetine more efficacious. That is a major pharmacological interaction right there, and I'm not sure if I would really like to play around with it. There might be more ways to boost vortioxetine? You're thinking it might not be strong enough compared to your MAOI?
Posted by Dispossessed on March 3, 2014, at 21:05:35
In reply to Re: Sudden sensitivity to SSRIs/side effects? » Dispossessed, posted by SLS on March 3, 2014, at 20:31:02
> I'm sorry to interrupt and ask a question that may have already been addressed, but how does your OCD manifest? Is it obsessions and ruminations only, or is there a compulsive counterpart including rituals?
Its pure OCD only. Basically, it is a fear that I lose control and either main/hurt myself or somebody else, even though its the last thing I want to do. Obviously, I have never lost control before but when the anxiety is bad I do fear that I would.
>
> I don't know. I am still looking at Latuda if you are ruminating and not experiencing compulsions. I have not researched this possibility well enough to recommend it, though. I would try the Brintellix first.Unfortunately both these medications are not available in the UK. The psychiatrist mentioned risperidone at the lowest possible dose, but only if I had titrated up an SSRI with only a partial response. I have concerns with antipsychotics, given the akathisia risk and the fact that most of them hit a lot of receptors (contributing to their huge side effect profile).
>
> How did you respond to Luvox and clomipramine?Fluvoxamine appeared to reduce the appearance of the thoughts somewhat, though conversely, it increased my anxiety/restlessness/sense of dread. I was also very careful to avoid anything that could potentially increase anxiety, like caffeine/alcohol, which may have played a role. The good aspects of fluvoxamine were its limited effect on cognition, vision and sexual function. Clomipramine I only took for 11 days. Even though I was only taking 25mg, I experienced severe blurred vision and dizziness that prevented me driving, delayed ejaculation, GI problems and a lot of flatulence, and a general sense of somnolence.
>
> Perhaps Phiddipus can comment on combining Brintellix and nortriptyline. You would be adding NRI + 5-HT2a antagonism. Both drugs are metabolized by the same enzyme (CYP450 2D6), though. You might have to reduce the dosage of nortriptyline. With nortriptyline, you can get blood tests to use as a guideline for dosing. Adding the nortriptyline might help with depression, ruminations, and the anxiety that accompanies depression (as opposed to an anxiety disorder).I would definitely be open to trying another tricyclic, but the cognitive/visual side effects would be the killer. For some reason I experience adverse effects from drugs that antagonise histamine or muscarinic receptors. Sertraline (25mg) caused a lot of cognitive problems, blurred vision, a general sense of fatigue (went walking one day and I struggled climbing a hill) - though incidentally it improved sexual functioning slightly. I gave it 4.5 weeks before deciding the side effects were preventing me from getting on with my studies. How long should I have given these side effects to fade? Should I have given it 2-3 months?
Citalopram made me feel pretty sedated - was great for the anxiety/OCD, but again, it had some pretty nasty cognitive and visual problems, owing to its mild antihistamine effect. I took it for 5 months at a very low dose and these side effects didn't go away.
Anyone got any reason why I'm sensitive to these side effects?
>
>
> - Scott
Posted by LouisianaSportsman on March 3, 2014, at 21:10:16
In reply to Re: Sudden sensitivity to SSRIs/side effects? » Dispossessed, posted by SLS on March 3, 2014, at 20:31:02
> (as opposed to an anxiety disorder).
>
>
> - Scottmissed this part, but I can't edit my whole part out earlier. wasted my time writing it -.-
Posted by LouisianaSportsman on March 3, 2014, at 21:18:49
In reply to Re: Sudden sensitivity to SSRIs/side effects?, posted by Dispossessed on March 3, 2014, at 21:05:35
> Anyone got any reason why I'm sensitive to these side effects?
>
> >I've yet to hear of this tricyclic you've tried named one time in the thread? Everything you've tried has been of the SSRI variety. That's why we want to know how a TCA might effect you. You may not be as sensitive to it at responsible dosing.
I'm not sure about trying Luvox, it might be a waste of your time.
Have you considered Lyrica (pregabalin)? If you're sensitive to this, you may be sensitive to that too, but that is something that might actually work for your OCD too.
Posted by phidippus on March 4, 2014, at 1:31:02
In reply to Re: Sudden sensitivity to SSRIs/side effects?, posted by Dispossessed on March 3, 2014, at 21:05:35
Eric,
> Its pure OCD only. Basically, it is a fear that I lose control and either main/hurt myself or somebody else
These are my main obsessions as well and I have brought them under great control with Brintellix.
Have you done much exposure therapy for these thoughts? For instance have you tried to lose control or pretended to kill yourself?
A very effective method of handling these thoughts is to agree with them until they lose their power. Purposefully imagine yourself taking your life in a comical manner-for some reason, I find killing myself with a lawn mower to be totally hilarious.
>I have concerns with antipsychotics, given the akathisia risk and the fact that most of them hit a lot of receptors (contributing to their huge side effect profile).
In persons with OCD it is often found there is excessive output of dopamine in the nucleus accumbens. Sometimes an SSRI is not enough to treat OCD adequately, so APs are used to control the excess dopamine which may be an issue.
Just because APs have a huge side effect profile doesn't mean you're going to experience them. As for AP induced akathisia, it is much easier to treat than SSRI induced akathisia.
> I was also very careful to avoid anything that could potentially increase anxiety, like caffeine/alcohol
Studies have shown that both caffeine and alcohol have positive effects on OCD.
>Even though I was only taking 25mg, I experienced...
I wonder if some of the side effects you experience from medication are psychosomatic.
> > Perhaps Phiddipus can comment on combining Brintellix and nortriptyline.
I have never tried it.
> I would definitely be open to trying another tricyclic
Clomipramine is the only one studied in the treatment of OCD.
>How long should I have given these side effects to fade? Should I have given it 2-3 months?
With SSRIs I give it about 6 weeks before I give up because of side effects. And I am talking about a therapeutic dose-so for Zoloft it would have been 200-400 mg.
> Anyone got any reason why I'm sensitive to these side effects?
Take higher doses for longer periods of time and see what happens.
Eric
Posted by phidippus on March 4, 2014, at 1:43:44
In reply to Re: Sudden sensitivity to SSRIs/side effects?, posted by LouisianaSportsman on March 3, 2014, at 21:02:20
>"no AP without AD" philosophy you have, Eric.
Philosophy? Any prescribing psychiatrist worth his salt knows this as common knowledge. Why, even Wikipedia warns against.
>the 5-HT2A antagonism which is balanced out by 5-HT1a partial agonism
I don't think thats how it works.
> Lurasidone also has less of a cognitive imprint with its D2 receptor blockade pattern
The target of dopamine antagonism in OCDis the nucleus accumbens, which has a higher density of D1 and D3 receptors.
Eric
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