Interested in your opinion

Edited , 5 users are following.

I know from my own experiences of this forum over the years that it's very difficult for others to give definitive advice as there are so many unique factors. But I am interested to hear what others would do if they were in the same situation as me.

I suffer from acute episodes of insomnia which then cause horrific anxiety attacks, which then cause insomnia. When it happens, it happens really bad and I had a huge crash last summer - the worst it's ever been. Outside of these "episodes" I am completely fine, for months and sometimes years - no anxiety, no insomnia. Last summer when the crash happened I was put on Mirtazapine and Escitalopram. It's no exaggeration to say that the Mirt literally saved my life. Yes it makes you put weight on which is horrible. Yes it (like all other antidepressants) is usually hard to come off. Yes there are start up side effects. But what it did for my sleep and to save my life made it worth it ten fold.

Because of the weight gain I have been tapering off it pretty much since I started taking it, at a 10% taper once a month - anything more than this gave me WD. I have managed to taper down to 2.7mg now. My Escitalporam dose is 5.5mg

I have been absolutely fine for months and months - I didn't even feel the Mirt was causing me to sleep anymore but I was still sleeping fine. Then on Tuesday this week an upsetting event occurred which triggered another spiral. I didn't sleep at all and then have had acute anxiety attacks in the early evening every day since. I whacked my Mirt dose back up to 5mg in order to sleep, and last night had to put it back up to 7.5mg. I have also had to take 2.5mg Diazepam the last two evenings at about 6pm because the anxiety attacks have been so bad. I am very aware that messing around with my Mirt dose is a bad idea - I need to stick to one thing. The conflict comes because I have worked so hard at tapering, it has taken so long, and I have recently lost 9 pounds from it, that it's soul destroying to just lose 6 months work in the space of two days. But I also know the most important thing is stabilizing myself.

Does anyone have any advice on what Mirt dose they would stick with, if they had been on 2.7mg and then suffered from another insomnia episode? Just to reiterate this episode was not caused by withdrawal, it was a life event that was nothing to do with my meds. Would you also increase your Escitalopram to deal with the anxiety or do you think it's better to do one thing at a time and use the Diazepam to help deal with that on a short term basis? (Once I sleep fine, I have no anxiety).

All thoughts and opinions welcomed xxx

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13 Replies

  • Posted

    Hi

    You relapsed because you came off of a therapeutic dose of mirtazapine. Can i ask why you came off? was it bc of weight gain? i think unfortunately you are going to have to consider the trade off between controlling your insomnia and anxiety and weight (if thats the case).

    i had the same dilemma. ultimately i chose go back on it because life was too short to be ill. you can lose weight on it, its just harder than it would be normally. the therapeutic dose is 15mg. just stay on that and live a happy life is my opinion. you could probablty cut the other one as thats a pure antidepressant. why are you on that anyway? it doesnt help sleep

    longer term you may want to consider therapy to find out why you suffer from chronic insomnia? have you ever looked into that?

    short version: you relapsed bc you came off a therapeutic dose. so go back on it

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  • Posted

    In my tapering experience I also encountered moments when I was scared about insomnia coming back but I always decided to keep the last dose and after three or four days of sleeping for only two or three hours things settled and I could continue.

    At the moment I am about to end the 6th week of withdrawal and I still struggle with the sleep but besides the usual hard to fall asleep and waking up after three, four hours I had also nights with seven or even eight hours of solid sleep.

    I had anxiety during use of mirtazapine and I still have it because in my case the cause is not solved, but during tapering and withdrawal our usual anxiety is often doubled by the not sleeping anxiety.

    I reckon that in your case this week event probably trigger a high release of cortisol and adrenaline that remained very high during the next days and prevented the mirtazapine to help inducing sleep.

    In my case I felt sedation with mirtazapine even at the dose of 0.5 mg, but generally in the days when anxiety was higher than usual the sleep was not so good.

    I would advice to try to keep the good work of tapering that you did by now and do anything helpful to asses a little bit the anxiety. For keeping my anxiety in check I use meditation, abdominal breathing, 4-7-8 breathing technique and supplements like Holy Basil (Tulsi), L - Theanine, Lemon Balm and Valerian (which is also good for me in this moment for sleep).

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    • Posted

      Thanks @marius1976 for your kind reply. You're a stronger person than I am, managing to hold at the same dose after insomnia! I suppose I did have the odd one or two nights of insomnia during my taper (caused by minor WD) and I was able to ignore those and carry on. But this time it was like my insomnia of old, with no sleep at all and sky high anxiety (sweating, nausea, all the good stuff). I just wasn't able to ride it out. I think you're spot on with what happened this week - the event (my cat stopped breathing in front of me and had to be taken to an emergency vet overnight and I was extremely anxious and upset about it) caused a spike in cortisol and adrenaline and I have discovered that once I get into that state (whatever the trigger) I find it impossible to sleep, which then makes the anxiety even worse - it's a viscious cycle that I'm sure others can relate to! The crazy thing is that outside of this episodes / triggers / spikes, I am totally fine and have no sleeping problems or anxiety. It's just when I do get it, it gets really, really bad.

      Thanks for the supplement suggestions - I have always liked giving things like that a go so will try what you've recommended.

      @greg72776 I truly don't believe I relapsed specifically because I was on a low dose, I think I had a really upsetting / traumatising event and the dose I was on wasn't high enough to tranquilise me to sleep anymore after it - although maybe that's the same thing?! The frustrating thing is that outside of these "episodes" which can be a year or more apart, I don't suffer from sleeping problems or anxiety - even when I'm on no drugs at all. It's just that when I do have an episode, it gets really bad. That's why I find it tough to accept being on all this medication long term. You're right that living a happy life is much, much more important than weight. Logically I know that I find it a hard thing to accept when I'm feeling well.

      Thanks for the replies, really appreciate it x

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    • Posted

      Np. I wish you well. I will add that I came off easily in 2017. A very quick taper and no side effects. I also slept normally. The reason I went back was my depression and anxiety returned at around the 4/5 month mark. My pharmacologist said it was because I’d stopped the mirtazapine and tbh I think he’s right. Because obsessional thoughts about all sorts of things returned by month 1/2. So for me, I’ve accepted that in order to be stable/happy I stay at 15mg for life.

      You could experiment with doses to see which ones help you sleep. I’d say 7.5mg was the minimum.

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    • Posted

      It's good to hear that you were able to come off without any problems - so many people including myself haven't been able to, but I always say - the people who DON'T have problems are often not posting about that on forums!! So there can be a biased and scary view out there. My brother in law was on it and also had no problems doing the doctor recommended taper which is way quicker than 10% a month.

      It sounds like you've made the right decision for you by staying on it. I honestly can't say enough how Mirtazapine literally saved my life because it's the only sleeping pill of any kind that works for me when I have one of my 'episodes'. It's just such a shame that the trade off for that is I have to be on it for years because I can't come off quickly and the weight gain. There is a lot of information out there to say that 7.5mg is the better dose for sleep, as the more you take the more the noradrenaline starts to counteract the histamine aspect of it. The jury still seems to be out on it though!

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  • Posted

    I also had a first good reaction to mirtazapine in the moment I have started it helping me to sleep from day one and absolutely no starting side effects. This followed one year of struggle with passing from one benzo to another or from one AD to another just to find that I cannot stand SSRI's and SNRI's. I have passed through a difficult cold turkey quitting of clonazepam which had many months effects on anxiety, then my sleep relied for around 4 months on trazodone + zopiclone used daily till I decided I do not want anymore the zopiclone.

    I was on mirtazapine at 30 mg for 5 months but for me there was no difference in using 15 mg or 7.5 mg.

    I had no side effects when changing the doses, but after 5 months I was having a very strange feeling in my head during mornings, something like oversedation but more complicated and it started to be impossible for me to focus and do my job. Finally I decided to quit the stressing job and to focus on stopping the mirtazapine. Now I see it as a right decision because I got rid of that problem and now I feel like old myself. The taper itself was not very difficult having some problems at lower doses (around 2 mg ), but after quitting 6 weeks ago insomnia restarted and I still struggle as I expected but being more informed than in the past I keep on resisting.

    Mirtazapine was good for sleep but as any AD it just covered the anxiety which is still present being linked to the uncertainty regarding my next job and future safety (not luck for me to start the discontinuation at the same time with the virus caused lockdown).

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  • Edited

    Can you see if this blip passes over the next week or so?

    Otherwise...

    Gut reaction: up the Escitalopram, keep the Mirtazapine low.

    Since you're already on Escitalopram, and a relatively low dose, there's room for manoeuvre and it should target the anxiety but it has a different side effect profile than Mirt so may be preferable for you?

    Mirtazapine is definitely more sedating at lower doses where all you're really getting is the antihistamine effect, hence the sleep. I know that some people on higher doses (e.g. 45mg) find it too activating. (I found that some nights chipping off a piece not much different to a grain of rice was enough for sleep, though obviously YMMV depending on sensitivity/tolerance etc.)

    I realise this is more of a 'long game' approach as a change in Escitalopram won't have immediate effects but since your aim has been to reduce Mirt I think it's more in keeping with your plan.

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    • Edited

      Thanks for the reply @Charlie_T. Oh gosh, now I really am confused with the right thing to do! I keep switching between which strategy is best and I had settled on the opposite this morning!!

      Whatever happens I am back at 7.5mg of Mirt now. Once I've stablised with everything I'll begin the slow taper again.

      I have two choices/strategies with all of this long term: either I increase the Escitalopram to 10mg and hope that if I stay on it (forever) it will be enough to prevent any of these insomnia episodes happening in the future. I have been on SSRIs for years and they haven't prevented them in the past, but I've only ever been on a tiny dose (eg 25mg Sertraline). Or, I come off the Escitalopram completely, taper down off the Mirt and then when I have another episode at some point just increase the Mirt to 7.5mg again and then slow taper, knowing that Mirt 100% works to get me out of these spirals.

      I guess the key thing (and what's impossible to know) is whether being on a high dose of Escitalopram on its own (forever) would be enough to prevent me having another episode and never needing Mirt again. If it isn't, then when another spiral happens in 6 months or a year, I'll end up being on both a high dose of Escitalopram AND needing to start the Mirt all over again.

      Super hard to decide what is right 😦

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    • Posted

      True - I just feel that I need for the sedation aspect to get me out of this insomnia blip. I've had a think about things and I'm going to slowly increase the Escitalopram to 10mg and, once I've stabilised on the Mir,t continue my slow taper off that. I thought about what you said, and also realised that apart from a period of about 6 months a few years ago I have never actually been on a full / recommended dose of any SSRI. I have always taken eg 5mg Escitalopram or 25mg Sertraline, neither of which are theraputic doses., so I can't ever really know if they are effective at preventing these episodes for me. If it still happens then I know the Escitalopram is making no difference / not helping, but at least I've given it a shot. I may also consider increasing from 10mg to 15mg Escitalopram as the summer months approach as a kind of preventative attempt, because without exception every time this happens (whether coincidence or not) it's around this time of year.

      A question - what's your opinion / experience on ADs (specifically SSRIs) stopping working after a while? I have always felt that after an initial couple of months that they do - like my brain just adjusts it's levels to suit the meds it's getting and I feel back to normal. And if this is true then my above strategy will be rendered useless 😄

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    • Posted

      Therapeutic doses do seem to be different for different people and at different stages of their recovery.

      Honestly, I've never found SSRIs do that much for me, I do seem to be very sensitive to them but nobody seems to know if that's a good or bad sign! (Sertraline and Citalopram are about the same - emotion blunting and mess with sleep, Prozac was intolerable - it was scary how anxious it made me, Mirtazapine made me sleep and put on weight but I think the antihistamine effect actually made anxiety worse and the withdrawal caused my current predicament)

      It's all trial and error, which is basically my take on your question. Has it really stopped working or is it a 'blip'? (needs time to see) or has your body adjusted and effectively achieved its previous state?

      The options are as always:

      • Wait
      • Go up until your body can't 'fight' the the therapeutic effects
      • Switch (or add in something else)

      Curious that you find Summer worse (a lot of people find Winter bad for obvious reasons) I'm just wondering what changes affect you? (simple things like is your bedroom blacked-out, do you get hayfever, is the bedroom too warm etc.)

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    • Edited

      Therapeutic doses do seem to be different for different people and at different stages of their recovery.

      Honestly, I've never found SSRIs do that much for me, I do seem to be very sensitive to them but nobody seems to know if that's a good or bad sign! (Sertraline and Citalopram are about the same - emotion blunting and mess with sleep, Prozac was intolerable - it was scary how anxious it made me, Mirtazapine made me sleep and put on weight but I think the antihistamine effect actually made anxiety worse and the withdrawal caused my current predicament)

      It's all trial and error, which is basically my take on your question. Has it really stopped working or is it a 'blip'? (needs time to see) or has your body adjusted and effectively achieved its previous state?

      The options are as always:

      • Wait
      • Go up until your body can't 'fight' the therapeutic effects
      • Switch (or add in something else)

      Curious that you find Summer worse (a lot of people find Winter bad for obvious reasons) I'm just wondering what changes affect you? (simple things like is your bedroom blacked-out, do you get hayfever, is the bedroom too warm etc. are probably far too small to cause the problem but maybe they exacerbate it)

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