Go to 15mg mirtazapine for a week, then straight to 20mg fluoxetine?

Ah okay thank you for the information, that makes complete sense now. I just didn't think itd be safe to do it so quickly.

And i have very severe anxiety, I've had it my entire life with social anxiety and general anxiety. I'm actually doing CBT at the minute and its been very effective. Before i started it, i wasn't leaving the house at all and felt lost, but now im doing things again. Im also practising meditation and its working really well as i suffer with insomnia too so it helps me sleep.

In regards to sertraline, i did try to start on that before after completely tapering off the mirtazapine. Now that i come to think of it, i think i didn't get on with it because i mistaked the withdrawal symptoms from the mirtazapine as sertraline not working and making me worse. I just really hope fluozetine works because even now I'm getting very horrible thoughts and mood swings. I also found myself crying and i didn't know why. I just feel a lot of built up anger inside me and i just couldn't help it. Do you know if this is normal? Thanks for your advise i appreciate it

great that you're doing cbt and meditation as well.

i'm not sure to what your question is related?

- do you mean like is it normal to have these crying spells during a withdrawal period or in general?

these drugs (psychopharamcological drugs) are all very powerful and can have many effects and this different from individuals unfortunately, which is why i think they should only be used as a last resort when everything else has failed or the suffering is too impairing.

from my own experience i can say that i've never had such cryingspells before i started the medication and i only have them when i try to quit. also i don't know in these situations why i have them because there is no external source like a fight with someone or anything that would have really caused the sadness in such a severity. i think in these situations it is best to remind ourselves that this is an effect of the medication.

since you suffer from anxiety and were unable to leave the house and have troubles with antidepressants there is always the possibility for short term use of benzodiazepins such as lorazepam for immediate relieve, until a new medication works. benzos are also not the first choice as they can make people addictive yet on a short term and under supervision of a doctor it seems justifiable to use such.

hope this helps. otherwise don't bother to reply ;-)

Hi, sorry my PC ran into some issues and I've just managed to fix it. I start the fluoxetine tomorrow, but lately the anxiety is really extreme. I will worry about everything even if i can rationalise a situation. I just can't wait to Start them as its getting unbareable. I also keep getting cold callers which is driving me insane and making me panic. I may suggest that to a doctor in regards to the benzos. Im just eager for some relief at the moment. I will keep the forum posted how i settle in with the new meds. Thanks for all the help.

hey you,

stay strong! there is a good chance the fluoxetine will easen your symptoms. yet you know it can take some time for it to work and you might have initially some side effects as nausea etc. which will normally subside with time.

in the mean time you could try to drink some calming teas such as camomille, lavender and what is all out there. try some herbal medicine such as valerian, hop, melissa. meditation, breathing and mindfulness practices have also shown to bring some relief.

also keep in mind that your thoughts are only thoughts. it may help to try to step back a bit and observe your thoughts. with this technique you take notice of your thoughts as an observer and you do not judge nor try to control or change them, yet you acknowledge that these thoughts are there and they come and go. this may help to get some distance from disturbing thoughts as you realise they're simply thoughts, they're not you.

please keep us informed on your progress and let us know if we can be of help. you can do this!

Hey, i took my first dose of flouroxetine earlier and i must say it gave me quite the buzz! I felt like i could concentrate much better and it gave me a lot of energy. Unfortunately its wore off now and i feel really lousy again. I forgot to take my mirtazapine last night so I'll make sure i have it tonight because i slept awfully. I have been using headspace and practising mindfullness and it does help. Also thanks for the advise on realising my thoughts are just thoughts and not to pass so much judgement.

I feel good about this medication change but I'm just concerned about insomnia, because i do struggle with that and i fear when i stop the mirtazapine completely, it will get unbareable.

hey thanks for the update!

although it is possible to feel immediate effects with these drugs they mostly take time to appear. so i wouldn't be too concerned yet about the effects fading away later in the day. it takes a few days of intake to reach a steady state and then it might take a few weeks (normally 2-3) before you really feel the effects. one good thing about fluoxetine is that it has about the largest half-life of all antidepressants that are currently on the market which means that the concentration in the body will be very constant and it's not that tragic or noticable if one misses a dose as it is the case with other meds such as duloxetine or venlafaxine.

about your concerns about insomnia. if you think about it rationally it can go 2 ways. either you get it or you don't. if you get it there is a lot you can do about that. the first and in my opinion the most important thing is to have a good circadian rhythm, meaning that you go to bed at a specific time and you get up at another specific time each day. since you say you struggle with insomnia i take you probably have a disturbed rhythm and it might make sense to look into that.

there are plenty of remedies that can help you fall asleep and stay asleep so you can build your rhythm. psychiatrists often prescribe trimipramine for patients having trouble falling asleep. this is originally a tricyclic antidepressant but is used for its sedative and anxiolytic effects to help sleep. and you can take it whenever you have troubles sleeping. also building a circadian rhythm takes about a month as your body needs time to program its inner clock. once you have it you should keep it up for most of the days as this will help you generally to feel more rested and relaxed. if insomnia still persists after that you might want to take it further. yet i'm confident as in most cases this helps quite well.

to support your sleep you could also use valerian tablets. they take about a week or two until you can sleep very relaxed yet they don't make you sleepy and may not help you falling asleep but only make you sleep better and feel more relaxed.

do you know what keeps you up? are you thinking too much or something specific?

regards,

d

Hello again, you're absolutely right. I think i got my hopes really high when i felt that sudden relief initially, but hopefully i can feel like that all the time once its properly in my system.

In regards to sleep, i think id benefit from seeing a psychiatrist because doctors never diagnose me, i have to do that myself. So a lot of the time they don't know how to help me and just brush me off by putting me on another pill. Im gonna try and get my routines sorted again this week and go to the gym to help with sleep. Hopefully with that and meditation I'll be able to manage.

My insomnia is mostly not being able to stay asleep, i managed okay on mirtazapine because they had a sedative effect so i think i will miss that. Last night for instance when i forgot to take my mirtazapine, i was up in a few hours and just couldn't then fall into a deep sleep. Just light sleep where I find myself looking at the clock in an hour wondering if I've actually been sleeping or not. Thanks for your continued support!

hello beezwax,

i was wondering how you're doing so far on fluoxetine and with the sleep?

greetz,

d

Hello again Dr. D, nice to hear from you again. I've been rather bad lately with anxiety, i haven't been eating and have been having thoughts that have scared me. I've seen the doc again and he's put me on 2mg of diazapam 3 times a day. Its not helping much, but i guess i just have to wait for the fluoxetine to get in my system. I can be fine one second, then a troubling thought related to anxiety will make me feel ill and sick to my stomach. In regards to the sleep, I'm surprisingly doing okay. I feel like the quality of sleep I'm getting is better now that I'm off mirt. I'm just praying i feel myself again soon because I've felt like a different person almost lately and its been scaring me. Its got to be down to the anxiety, so I'm just trying to think its temporary

hey you,

i'm very sorry to hear you have these troubles at the moment. hopefully you can find a psychiatrist that has a good knowledge about psychotropic drugs. depending on what country you live and what health care system you have you might need a referral from your GP or can make a direct appointment with one. to be sure your insurance will cover it i suggest to ask them how to proceed or look up the information on their website.

about the symptoms you currently face i could come up with a few hypotheses:

1) your symptoms are related to your body now beeing without mirtazapine (not withdrawal yet the state you're in without the effects of the medication) plus fluoxetine has not yet reached its full effectiveness (it is too early to tell since you take it only about 2 weeks).

2) you're actually facing withdrawal from mirtazapine

3) you're a non responder to fluoxetine

4) your dose of fluoxetine is too low

5) fluoxetine has not started working yet

6) fluoxetine is generating your symptoms

regarding you mentioning diazepam 2mg 3x daily not feeling much help could be because 6mg daily is at the lower end of the recommended dose range for symptomatic relieve of anxiety and panic relieve. at least according to swiss pharmaceutical guidelines the recommended daily doses for oral intake range from 5-20mg, with an initial dose of 5-10mg and oral single doses should not be higher than 10mg. of course the dosing is always depending on the age and constitution of a person. ask your doctor for the upper limit of diazepam you could take. it may make the difference.

regarding your state in general:

it is always difficult to assess how much "pain" someone can tolerate and in such phases of change of medication this can sometimes take some time which can be very debilitating and poses therefore an increased risk for a person to lose its functionality, eventually ending up in hospital which is what one tries to prevent of course.

if a person receives outpatient treatment they should be monitored closely in these phases, so weekly appointments are suggested until a degree of stability is reached.

- what dose of fluoxetine do you currently take?

- how often are you seeing your gp/therapist now?

- how much are you suffering from your current symptoms? do you feel like you can handle it easily, fairly, barely? 

greetings,

d

Hiya, yes I will definitely ask about it when I next see my Doctor which is Tuesday, and I can also ask my Therapist on Thursday about it. I think most of your numbered points could be the cause of all of this. I know for a fact Mirtazapine doesn't effect the same neuro transmitters as the Fluoxetine so I feel my body is freaking out because they aren't getting the same chemical in the receptors. I'm all for waiting to see if Fluoxetine will do the job, but the anxiety is very severe and its the thoughts that I get in my head that trigger it most of the time. Its a thought of harming a Family member who I love very much, I have put it down to anxiety though. Its like a complete panic attack of fear induced by this thought. I think I need to not take this thought so seriously because my heads just all over the place at the minute. Its just scary when the thought happens and I have to keep telling myself that I love my Family and stuff. It gets kind of compulsive and I just don't feel like myself. I'm just trying to be around them and talk to them more, but I tend to get really upset because I don't know why I'm thinking these thoughts. I know its all anxiety so I just try and remember that it will pass.

I take 20mg Fluoxetine at the minute along with the Diazapam. I would say I'd see them on average every 2 weeks, but I often don't feel thats enough when I'm having these breakdowns. And my symptoms seem to be uncontrollable. I've always had this anxiety feeling thats gotten worse as I've aged, I can get temporary relief from things such as meditation and things but lately I've been looking forward to going to bed so I can get a few hours of relief. I've not been doing much with my time lately because I feel incapable of doing so, I think I'm gonna really have to force myself starting tomorrow to get me doing things again and hopefully relieving this stress. Thanks for your continued support.

Hiya, I'm from the UK.

hey,

have you had these specific thoughts about harming a family member prior to taking fluoxetine or did they start with the intake of fluoxetine?

there are reports of people harming themselves, family members or other people while on psychotropic drugs. although it is hard to say whether the pills cause this or just make people more susceptible to such thoughts i think you should mention this to your GP and therapist. i'm always concerned when people speak about self-harming or harming others and this should be taken seriously.

i don't know about your familial situation and whether they know about your anxiety and you taking meds. despite that it seems you can cope with these thoughts at the moment it seems appropriate to let them know about this. this way they may notice changes and would be able to act before something happens.

please understand me right, i'm not trying to scare you or create even more anxiety by telling you this. but i think it's better to be proactive and have it under some control rather then to do nothing. of course i can not see what's going on in your head and even if you can manage it at this point - which is great and to me you make the impression you can deal with it -, yet something unexpected could happen that could set you up and we simply want to make sure to have done everything we can to prevent anyone from harm.

hang in there!

d

Hey, these thoughts started when starting fluoxetine. I think i am just in a strange anxiety fueled mindset at the moment and its making me think extreme thoughts. I would never hurt any member of my family in a million years. Its just been causing me distress that i had that thought in the first place so i haven't been able to let it go. Its very hard to explain. I feel really guilty because i have put my family through so much with my mental illness and calling myself a burden feels like an understatement. They're very supportive and know all about my issues and drugs I'm taking. I just feel very depressed at the moment, more so for my family because i can tell it makes them upset to see me struggling so much. I just want to make it clear i would never harm any of my family, i care and love them more than anything. I just feel this drug transition is making me freak out about things and over think my worst nightmares it seems.

heya,

i think you're doing a great job in managing yourself and it seems like you're in touch with what's going on. i bet you would do the same for anyone in your family if they were in a similar situation, hence try to accept it as it is. there is no need to feel guilty as true love is unconditional and appreciation is probably the greatest way to give back for what you receive.

regards,

d

Hey, just an update on my situation. I just came home from seeing the doctor and told him about all the thoughts I've been getting and side effects. He referring me to someone in the mental health team just to be safe, but i told him I've been very anxiety fueled every single day so i believe these thoughts are down to anxiety. If anything, i feel closer to my family now. I tell them I love them everyday and get very emotional behind closed doors because i can't understand why I'd get these thoughts. He's decided to double my dose of fluoxetine to 40mg to see if that helps. Also because i said about the fact i never had these thoughts on mirtazapine, he did give me that option to go back onto them. But this would all be for nothing and i was very unhappy on that drug. I'm just going to try and ride this out and get my mind focused on things so i don't dwell on how bad I'm coping. Worst case scenario, i go back on mirtazapine. I just want these thoughts to stop.

hi, thanks for the update.

good to hear your doctor referred you to someone in the mental health team.

regarding your perspective it might not work out and in the worst case you go back on mirtazapine. i would not think of it as a worst case rather than as the "fall back" scenario. this is a safe value, you know how you were when taking mirt and you know it might not be ideal but to some degree you could manage, right?

plus there are plenty of other meds you can try. talk with your psychiatrist about options. like "what are we going to do if this does not work? what you could do in the meantime when you're not yet in the responsive phase (maybe short term use of tranqulizers such as lorazepam could be used to ease the anxiety until the meds kick in).

there are plenty of options, so please speak openly with your psychiatrist on what you've already tried, how this went, what symptoms are bothering you and what you wish for the future. he surely is able to provide you different options and treatment plans.

regards,

d

Hey, I managed to speak to my therapist yesterday and she really put my mind at rest over the thoughts I've been getting. She said its anxiety fueled intrusive thoughts because they go against all of my morals and I have no intention to plan or act them out. That's really put my mind at rest and I'm moving on from that very successfully and starting to see light again. 

I feel my anxiety has been much better the past 3 days, maybe the fluoxetine is starting to kick in? I am also on 40mg now so thats probably helping it get into my system quicker. I have also not needed to have a diazepam in the day lately so that already tells me that I'm much calmer and in a better state of mind which I'm relieved about. The issue I'm getting right now is not being able to get much sleep. For the past 4 days I have only been getting around 3-4 hours so I've been starting my day exhausted and ending it exhausted. Its not affecting my mood as much as lack of sleep did on Mirtazapine, but its definitely still stopping me for doing a lot of plans. I'm hoping this insomnia is a bout and will die out once the meds properly in my system. 

Thanks for the advise on how to get the help from a psychiatrist, as I said though. I'm starting to stabilize a little so I'm feeling more positive about everything, but I'll make sure I bring up all those points when I'm able to. 

This might be a very silly question, but my friends have been asking for me to go out with them for weeks now and because I've been in such a state, I've not been able to. My friends are heavy drinkers so it always turns into quite a lot of alcohol being consumed. I am torn between whether to go out or not. The positive is I'll get to see them and get out of the house and have some fun, but on the negative I know that alcohol can interact with medications. Maybe I'll have to give it more time. Anyway, as always thanks for your advise and support.

hey,

i’m glad you’re doing better!

regarding your troubles with sleeping. can you explain this a bit more?

how does this present itself?

-          are you having trouble falling asleep?

-          are you having trouble staying asleep?

-          do you wake up a lot and you can easily fall back asleep?

-          do you feel like you don’t get deep sleep?

-          do you experience any other symptoms while sleeping such as night sweats, vivid dreams, etc.

-          do you eat a lot before bedtime? consume sweets or sugary drinks, coffeineited beverages?

-          what time do you go to bed?

-          what time to you have to get up? what time do you actually get up?

-          are there any disturbing factors such as noise, light, sound, pet, siblings, etc?

-          what room temperature is your bedroom?

-          do you feel relaxed when you go to bed or are you tense?

-          how about your mind? anything that keeps you from sleeping?

-          how much diazepam did you take lately (the days when you needed it) and when did you take it? before sleep?

-          do you exercise at least 4 hours before going to bed?

-          how do you spend your last hour before going to bed?

-          do you nap during daytime?

-          do you suffer from sleep apnoea?

it may be an adjustment period in connection with the medication change and it may go away. it could also stay that way or get worse. could also be that the increase to 40mg of fluoxetine causes this. could be hormonal. it is hard to say. I would try to find out if there is anything regarding your sleeping habits you can improve. and speak to your doctor/therapist/psychiatrist about it.

from my experience psychotropic drugs need to be dosed very individually. one person gets very sleepy from them so has to find the lowest dose the depression is bearable yet also he/she is not too drowsy. another one may experience insomnia and thus cut back to the smallest dose he/she can sleep while tolerating the anxiety.

some patients need to be co medicated as one med helps against depression but also makes the person so sleepy that a second drug with activating effects needs to instated. some change the meds until they find one that fits best for them.

one issue that should be considered is that people do not face lack of sleep over extended periods of time. one should be able to get a good night’s rest every few days. lack of sleep can make people depressed which is counterproductive when one already has issues in that area.

since you have a prescription of Valium, in case you have severe trouble sleeping you could use one of these as they’re sometimes prescribed to help people sleep. yet they should not be used as a regular sleeping aid. if the problem persists one needs to look deeper into it, maybe in a sleep clinic.

but for the moment I would wait a few days and see how you’re doing. and tell it to your therapists and see what they say.

regarding you going out…

what are you afraid of?

-          that you could drink too much? a beer, a glass of wine, or cocktail for sure is ok.

-          you seem like someone that is in good control of your actions yet I know group dynamics can put people under stress and then we may step out of that “one beer” we promised to ourself.

-          do you think you would not be accepted by your friends if you would not drink alcohol?

you know it’s always best not to drink alcohol regardless if someone takes meds or not 😉. my personal opinion is if someone has it under control everything is ok. if you feel that might be an issue you can do 3 things: a) stay at home and miss out on the fun or b) go out and don’t drink alcohol c) tell a good friend to keep an eye on you so you don’t drink too much or tell the bartender at the beginning to serve you only as much as you specify at the beginning.

my impression of you is that you’re very considerate and have yourself under good control. so whatever you do I feel confident you’re handling it very well.

have a nice weekend!

d

Hey! When I go to bed I can initially fall to sleep very easily, but within around 3 hours I am awake again and struggle to get back to sleep. I go into what feels like a very light sleep that doesn't feel restorative and I simply cannot stay asleep. I usually go to bed around midnight every night and my first awakening is usually around 3:30. I don't feel like I go to sleep again properly after that first awakening. I also feel a lot of anxiety in the morning upon waking and then there is a lot of things spinning around my head. My room temp and noise levels are down to a minimum and the room is very dark so theirs no problem on that front. My total time in bed trying to sleep is probably around 9 hours and then I often give up with it and go about my day. I meditate every night before bed and listen to some relaxing sounds, so I do go to bed extremely calm most of the time. Its honestly just the fact I can't stay asleep which is giving me the issues. I never nap during the day and lately I have been having a Diazepam just as I'm going to sleep. 

The first week on Fluoxetine, I was getting like 6 hours of pure sleep and it was honestly some of the best sleep I've had in years. Mirtazapine is known for helping with sleep, but I definitely slept better that first week than any of the time I was taking Mirt. I had very vivid dreams on them meds, never felt in deep sleep and also woke up frequently. I'm just gonna try and wait it out and plan out my days so I do stuff no matter how bad I feel. I'm not going to over burden myself with tasks but keeping myself busy will hopefully help this issue and I won't be thinking so much about the lack of sleep/anxiety ect. 

I did drink yesterday, but it made me very drowsy, emotional and talkative. Like I literally would not shut up lol. I didn't have as much as I'd usually have, but I still feel the effects hit me much harder than they usually do. I truly think if I can get the sleep under control, I will get on well with this medication because its already starting to help my anxiety after only close to 3 weeks. When I am tired on these meds I have noticed they make me feel very wired like I've had a lot of caffeine or something. I know in my head that I'm tired, but I still have that energy to get myself to do things? its weird. I have noticed my eyes look different since starting these meds. I feel like my eyes are more prominent and open and the pupils are very dilated like someone who is high. I went to the optician the other day and she mentioned that as well, I'm going to assume this will stop once my body gets used to the meds. I guess its not really a problem though. Thank you again, Sam

dilated pupils are very much a side effect from the fluoxetine. have you noticed any changes in heart rate or blood pressure?

I’m asking because you’re saying you’re having trouble sleeping respectively staying asleep and you mention that when you’re tired you still feel that energy to do things. since these drugs can have stimulating effects in some people while others feel sedated I think this is something you should keep an eye on. from what you’re describing the drugs have a stimulating effect on you which is a sign they’re working. but if the stimulation is too much, people tend not to rest properly anymore as they don’t feel they have to, they feel energized and so they may engage themselves in lots of activities hence losing the work-life balance. then at some point they’re overworked and become burned out.

one should really closely monitor the quality of sleep one gets while on these drugs. especially in the beginning. as I said in a previous post finding the right dosage is key. so in your case something between 20 and 40mg might be where the equilibrium for plenty of rest without too much anxiety is.

plus consider that alcohol can/will destroy sleep architecture.

sleep disturbances are also common in people with anxiety and depression. talk it over with your therapists and if it persists consider going into a sleep clinic to assess your sleep, they may notice something or may be able to give you remedies for better sleep.

kind regards,

dominic

Hey! Some nights are better than others but i just don't feel like i have proper sleep anymore. Last night for example, i slept from 12 till 3, then pretty much woke every single hour for the rest of the night and sometimes just lay there thinking rather than sleeping. Its just leaving me really exhausted even though the anxiety feels easier. I also seem to be making more jokes and feeling happier. Its honestly just the sleep which is the issue here at the moment.

In regards to my pupils and energy levels, don't get me wrong, i still feel incredibly tired, but there's like a different feeling of energy there probably similar to having a lot of caffeine. I feel like my heart rate has gotten slower if anything. I'm hoping its common for you to get this initially and then your body can sort itself out once the meds are in your system.

I have completely stopped the diazepam now, i was tempted last night but Id rather not go down the benzo route. Besides its effects were very minimal on the dose the doc prescribed. I will definitely talk this over with my therapist this Thursday. She mentioned i could be referred to a psychiatrist if i felt that would be more beneficial to go deeper. Thanks again, Sam