Saturday, September 22, 2007

What's Your Favorite SSRI?








And the poll results, of 105 respondents:

16 (15%)
25 (23%)
16 (15%)
14 (13%)
34 (32%)


Anonymous said...

Dinah, Do you think people can "get used to" an antidepressant they have been taking for many years? For me, Wellbutrin for probably 10 years. Does it help to switch to another one if this one seems to have stopped working?

Anonymous said...

Wondering where you stand on the issue of SSRI induced mania. Is it a side effect of the drug that only some people will get just as only some will gain weight on a certain drug and only some will develop dangerous skin rashes on others, or do you believe that it is a defintie indication that the pt has been misdaignosed and actually has bipolar? From what I can glean the current DSM does not assign a bipolar diagnosis if the mania was drug induced but it seems that in practice this is what is happening and medical histories are being re evaluated as doctors seek to relabel past events as manias. Is this good science? Is it the long arm of the drug companies reaching out to make sure that mania is not called a potential side effect of the drug? From what I have seen, the docs seem to be saying that a manic reaction means bipolar even in the absence of any previous manic episodes. It makes sense to discontinue the drug of course but what is behind the reaction? Can you give a sense of how prevalent a manic reaction to SSRIs is in your practice or of Roy's or Clink's? If you have already covered this elsewhere, please direct. Thank you.

Anonymous said...

kaliki: it's a scientific phenomena called SSRI poop out. Happens all the time. Adjusting the dose helps, often a lot.

Anon: I have no idea. My best guess is that anti-depressants precipitate manias in people with yet-to-be diagnosed bipolar disorder and some of these people will go on to have manias even off antidepressants. That's a guess. Some people with clear cut bipolar disorder go decades between manic episodes, so it's really hard to know what to say about someone who's only episode was med-induced except that time will tell and it seems to me that people with long periods between episodes of mood disorders and who's ONLY manic episodes were induced by antidepressants-- they tend to do well. If someone has a history of a manic episode on antidepressants...I don't prescribe them again, or if it's really needed, I ask the patient to go on a mood stabilizer first. Just my thoughts, please note these aren't based on any recent review of the literature. Other observations are invited.

Anonymous said...

I might as well have been taking a sugar pill in terms of achieving any positive effects from any of these medications.

When it came to the negative effects...with every one I had awful side effects while going on the medication, or while increasing the doses of the medications, while being on the medication, as well as during withdrawal from the medications.

Common were a feeling of depersonalization or dissociation, inability to orgasm, fatigue so bad I couldn't get off the couch.

While going on, or increasing doses it was like I had an awful flu...couldn't move, felt nauseous, crying all the time, sometimes I would have "zaps" going through my brain..."brain orgasms" I called them...not good though.

We tried to counteract some of the side effects with other meds, or increase the likelihood of them working with antipsychotics, or mood stabilizers, but either it did not help at all, or it was worse, or nothing helped for any extended period of time.

Not one of them was worth the effort trying them. Not sure why I seem to be the only one these, and all the 25-30 medications I've tried, don't work for? It is very frustrating and demoralizing. I have lost hope I will ever find a medication to help me.

Alison Cummins said...



Yup, had all of these on Paxil. One psychiatrist basically said That's Meds, Baby - that all medications have side effects and there's no point switching unless this medication's side effects are even worse than being suicidal. I hated Paxil so much I went off cold turkey and spent a week of nightmares and palpitations and nausea. Quite horrible.

Fortunately I found another psychiatrist a few months later - by which time I was an utter, weeping wreck who couldn't do the littlest thing without feeling like a doomed failure and bursting into tears - who seemed to think Of Course You Hated Paxil and started me on Zoloft. Which makes me a little spacier than I used to be, and now I might get a little headache every few weeks when I didn't get headaches at all before. That's it for side effects. Totally worth switching.

Anon2, I'm sorry switching didn't help you. Meds aren't the only option; are you discussing alternatives with your psychiatrist?

Anonymous said...

I just haven't done well on any of the SSRI's I've tried. Paxil was just an awful experience. I was dizzy, nauseous, getting brain zaps, anxious, and just an utter wreck. The shrink wouldn't listen to me and take me off, so I had my primary do it (bless her). She also switched me to Effexor right away, which changed my life! For me it's all about the SNRI.

Anonymous said...

I love, love, love wellbutrin. None of the straight up SSRI's were ever well tolerated. I had every single bad side effect possible on all of those. Despite not being the best candidate for Wellbutrin at first glance (because of anxiety... a common Wellbutrin side effect) it's been miraculous. No side effects at all (including weight loss and quitting smoking - too bad).

Anonymous said...

blib again... forgot I was going to comment on the mania issue.

I ended up with a bipolar diagnosis 2 weeks after I started on zoloft when I was 23. The next year was a nightmare of one mood stabilizer after another... every one of them made me feel sicker and sicker, more and more medications to counteract the side effects. Went off them all (cold turkey... I know better than that now). Despite the abrupt finish I felt immediately much, much better. I was so burned on psychiatry after that, I refused any treatment and all medications for about 10 years.

Midwife with a Knife said...

So, I'm just curious, how do you decide what to start with in a SSRI-naieve person with depression?

Dreaming again said...

My son is on Celexa for his OCD. He was started on Luvox and because of insurance change, he had to switch to Celexa.

Celexa, was significantly better. Convincing the 12 year old with OCD ... who was convinced since the doctor originally ordered luvox, and it was the insurance companies idea to switch, it MUST NOT BE A GOOD IDEA ...obsessed endlessly about it ..until the neuro upped the dose one dose. Then he was fine. ;) From an objective standpoint, Celexa was significantly better.

Personally ... I've been on paxil, prozac, effexor, then prozac.
I was started on Paxil, and I gained weight. Was switched to Prozac, lost LOTS of weight (I had an eating disorder the PCP was unaware of) and used the prozac to help supress my appetite ... when the PCP insisted I go to an eating disorder clinic for an evaluation ... the first thing they did ... remove me from the prozac. Put me on Effexor, but then, after a while blood pressure started to increase ...and I was placed back on the Prozac ...with the agreement that I let them know if my appetite dropped.

How in the world I managed to hang onto the prozac this last year, while in the midst of a relapse, is beyond me. My favorite, beloved Psychiatrist has left the clinic for a new position elsewhere, and my new psychiatrist immediately put the same connection the first psych did ... not eating + prozac ... um ...

So, I've been given till the first of the year to 'increase my caloric intake' or risk loosing my prozac to a 'weight neutral' SSRI ... yeah huh.

When she figures out that I'm also on Topomax as well as the prozac, I may not get to keep it regardless. (Topomax for migraine prevention)

Personally, I love prozac, but, right now, it's probably for the very wrong reasons.

Roy said...

I have so far resisted the urge to trounce on this one. I guess I could do posts on some of these, but will start with comments.

SSRI-induced mania and Bipolar disorder.
When I trained, this was referred to as Bipolar 3 (Bipolar 1 being classic, and Bipolar 2 being with hypomania rather than mania... sort of a Lite version). I have certainly seen a number of cases where someone's first manic episode was triggered by an SSRI or other antidepressant. I think most would call that person "Bipolar", which merely means someone with a mood disorder who has been manic or hypomanic in the past. That's pretty much all it means. Refers to a propensity to become manic.

Poop-out: There was an article on this in past 2-3 months, concluding that it wasn't so much the drug not working ("tachyphylaxis") so much as the illness getting worse. I'll see if I can find the reference.

Gotta go Jesso some canvases (canvi?).

Anonymous said...

I put Zoloft. Although Lexapro was a close second. Zoloft won because of the initial energy boost side effect. Mmmmm energy boost. Weight loss was also nice.

Lexapro was close second because out of those five, the only other one I'd tried was Luvox (more on that in a sec). I'm not convinced that escitalopram is superior to citalopram... but in terms of side effects, Lexapro was pretty good. As in, I can't recall having any.

Luvox is my second-least favourite antidepressant, and my least favourite SSRI. I didn't particularly notice any weight gain, however I did notice that I became extremely dopey and slept all the time. Which was not particularly cool.

I have been pondering the medication merry-go-round lately. To illustrate my ponderings, I must first list what I've tried (for "double depression")

Zoloft to 200mg - stopped because I couldn't sleep
Luvox to 150mg - stopped because I slept too much
Lexapro to 20mg... not quite doing the job, so added...
Reboxitine 2mg bd... oh no! Can't sleep again! Scratch that and Lexapro.
Efexor XR varying doses up to 450mg. Above about 300mg, can't sleep without my friend zolpidem.
Tried baby dose of Zyprexa (1.25mg at night - too much weight gain) and Seroquel (that's a whole different story... ended up having a couple of Seroquel crumbs of an evening). Then added mirtazapine instead. Helped a bit with sleep, made me eat like a horse, but still needed my 5mg zolpidem anyway.
Had a while on Efexor XR 450mg and zolpidem 5mg (not ideal, but it works). Then decreased Efexor to 375mg in a quest to sleep by myself (so far unsuccessful). And there we are now.

But what I'm thinking is, that I'm actually in the same situation as I was with a high dose of Zoloft - antidepressant + sleeping tablet. So was it worth the traipse through all the other drugs in an effort to find one that would allow cheer AND sleep? I'm not sure. I can see that if there WAS a drug that worked and had side effects that allowed normal function, it would have been great! And I think it's reasonable to note that the drugs I've had side effect problems with have all been at high doses. So it does seem reasonable to see if a normal therapeutic dose of something is more acceptable than a high dose of something else.

Being a fairly drug-savvy type of person, I didn't find the quest distressing in itself. My doctor generally makes the suggestions and justifies his opinion and as I know what he's talking about, I am able to argue or agree. But it is a lot of hassle.

So anyway, my choice for a patient who is antidepressant-naive would depend on how they present. But it'd probably be Zoloft or Lexapro/Celexa because of their relatively good side effect profile and effectiveness.

Anonymous said...

I got headaches from every single SSRI (ok, never tried Luvox), also from effexor, strattera, and ritalin. Ice-picky headaches that felt like something was trying to pry my coronal suture apart from the inside.

Rach said...

Anon (2nd comment from top) had my concern too... Mania induced from SSRIs... which is why your poll was not applicable to me :(

How about a "what's your favorite mood stabilizer" poll?

Anonymous said...

Well, the docs diagnosed bipolar 1, not 3. I think it depends on whether you go totally nuts or just get a little hyper or whether the doc believes in bipolar 3. I have read all the stuff about the bipolar sectrum but I think that if it isn't in the DSM then they don't really give you that diagnosis on paper. It may also have something to do with those nasty hallucinations plus prior hospitalizations. You might think that the history would have suggested to the SSRI prescriber that it wasn't a great idea. Hindsight is 20/20 so no more SSRIs.Having taken so many drugs my belief is that each one has so many side effects and that the SSRI induced mania is just another side effect that a person might get, like an allergy. I don't believe that makes me bipolar. It makes me SSRI intolerant.

Anonymous said...

I didn't go off any of the SSRI's because of side effects, I went off them because none of them worked. In fact the only things I went off because of side effects were olanzipine amd seroquel...I was a barely walking zombie on even minute doses.

My psychiatrist has mentioned/offered ECT in the near future if the med I'm on doesn't work...Which it doesn't seem to be.

I've had ECT before, but I'm a bit scared this time because a recent study came out saying memory loss is worse for people with bipolar who are having ECT for the second time:

I had some memory loss around the time of the treatments. I believe however, that some of my memory and cognitive problems now are related to being depressed for so long. My brain is pretty important to me, so I'm not sure what to make of the study and the choice of ECT again.

jcat said...

Anon 2 - I'm bipolar and have had ECT repeatedly. Apart from being a lucky draw whether it works or not, haven't noticed any increase in memory loss. Have always 'lost' the duration of the treatment almost entirely, although I seem to function just about normally. Bit of a bitch when people at work say 'we are having the same problem as we had last May, can you fix it again' and I have no recollection of May...never mind what I did to fix the problem! But it hasn't gotten worse - was like that the first time too.

Anonymous said...

I like the "what's your favorite mood stabilizer" poll idea!

Antidepressants are not my friends. They cause mania for me (the totally nuts kind). An SNRI-induced mania (Cymbalta) is actually how I got my dx of BP1. I've found that Paxil and Wellbutrin will do it too though. At this point I won't even touch AD's, not even with a mood stabilizer on board.

Anonymous said...

...I should add that I had previous unrecognized manias/hypomanias prior to the Cymbalta. The Cymbalta-induced mania was just a real wake up call that got us all on the right track. I don't think I fit into that Bipolar 3 category, and I'm a little skeptical as to whether it really exists in the first place (just my lay opinion).

Roy said...

My view on the "bipolar 3" category is that it is a different type of mood problem that the typical bipolar. I think a better categorization would be to differentiate between primary and secondary bipolar disorder. (My guess is that only psychiatrists (like me) who trained at certain institutions learned and used the term bipolar III.

Primary bipolar disorder would be one which can occur without a chemical trigger, while Secondary bipolar disorer would be one where one's mania or hypomania only occurs when triggered by a chemical, such as an SSRI, cocaine, speed, prednisone, sudafed, levaquin, etc.

The overlap, though, would be as in Michelle's case, where it initially looks like a secondary bipolar. Only on closer retrospective questioning and investigation can it be determined that there was a previously undiagnosed primary bipolar illness.

But I see no need to distinguish, say antidepressant-induced mania and steroid-induced mania. Not yet. However, current practice would likely result in most of the former being called "bipolar disorder" and most of the latter being called either "mood disorder NOS" or (more accurately) "substance-induced mood disorder".

Scott said...

I'm a Prozac man, myself. (As the patient. I'm not a doc.)

Anonymous said...

Jane Pauley's docs didn't see the difference(btw anti-depressant and steroid induced mania). I am waiting for all that great science to come and back it all up.
When they can give me a blood test I might believe that any of them know what they are talking about.

Anonymous said...

I actually didn't vote in this poll because I truly don't have a favorite SSRI. I would be commenting from the patient perspective, but the fact is that the majority of meds in these categories that I've tried were for headaches/chronic pain as opposed to depression. One of the very first meds I was given for headaches was nortriptyline (pamelor), and this actually ended an 8 day inpatient stay I was having by dropping my headache to a level 2. My mom and I were skeptical about my being on an AD and also the weight gain component (now I see how silly those worries were when the med had helped!), and so my neuro just simply switched to topamax without even trying to reason with us! I initially had bad side effects on only 25mg of topamax, so then we went back to pamelor, and I was on that for 2 years. I tried other TCAs - elavil made me sleep like 17-20 hours a day; desipramine - tried 2 doses before my psychiatrist convinced me to stop...neuro shouldn't have prescribed it....and I believe I've tried a few others, too - can't remember right now.

I have more experience with antiseizure meds that I was taking for headache than with SSRIs - took topamax, neurontin, depakote, lamictal, zonegran, lyrica, and I think there were others there, too. I have interesting stories about all of them. Lamictal was the best tolerated for me out of any and helped with vertigo/confusion auras I was having with migraines. Depakote helped with my constant migraine the best, but had such horrible side effects for me that I couldn't stay on it. I still receive IV depacon inpatient or in outpatient infusions if I have to. Not on any of these any longer.

But with the SSRIs come my stories. The first one was prozac. At the time we started this, I was in the hospital and was already taking pamelor, topamax, and verapamil for headache prevention - prozac was added on top of all these. (The most prevents I was ever on at a single time was 5 - can't remember the combination off the top of my head, though).

So I started with regular release prozac. I was a piano performance major at the time, and the worst side effect I was having from the prozac was uncontrollable shaking hands. Couldn't stop it. They were shaking all the time. So we went to extended release, and the shaking stopped. Unfortunately, I had a personality change on the prozac - I didn't care about anything - not even myself. My classic example comes when I was taking a chemistry class in college. The history is that I was high school valedictorian and never had gotten a B in my life until college, and was a piano performance major while also taking the required classes to attend med school. While on the prozac, I had a chem exam and received a 42% on it. I came home, saw the result, and said, "That sucks... What's for dinner?" and tossed the exam paper on a pile on my desk. I didn't care at all. I remember the day my mom had me call the neuro and have them take me off. We were having lunch, and I can't remember what we were talking about or what I said to her, but she recognized that I just didn't care about ANYTHING, and she said I had to come off it. What's funny was that my neuro prescribed it for chronic pain, but when I told him I needed to come off, he said to me, "I'm reluctant to take you off because I don't want your depression to get worse." Huh? I'm not on it for depression... The thing is, it would have been a great adjunct for me for severe depression if I was at the very end of my rope. I did not care - not an emotion in the world. I had no feelings. So if someone wanted to stop me from being suicidally depressed, then prozac works great - because I won't care enough to even think about suicide. So does that mean it achieved the desired effect? I would have had to drop out of school if I stayed on it, however! The other major side effect I experienced on prozac was a lack of any physical feeling, too. This is almost embarrassing to admit, but even when I had sexual desire, I had no feeling whatsoever - not only could I not orgasm on prozac, but I simply felt nothing. And unfortunately, my first sex experiences occurred while I was on prozac. Great way to kick off my sex life! ha...

The only other SSRI-like drug I took was cymbalta, which I know is more of an SNRI. I was put on this for headache prevention. Even a psychiatrist friend of mine thought I would do well on it because she has patients who take effexor and their migraines got better. Unfortunately, it didn't touch my headaches (hardly any of the over 50-100 prevents I've tried have affected my headaches, though...). It also gave me extreme anxiety - I had palpitations, and my heart was racing a lot. Part of this was that the palpitations/tachycardia came first and made me anxious - and sometimes it was because I was more anxious and the tachycardia/palpitations resulted. I have always had issues with tachycardia/palpitations that are unrelated to anxiety, but the two play off each other as well! I also, if this is possible while on an antidepressant, became more depressed - which seemed to be a direct result of the med, as it ceased soon after stopping the drug. I cried every single day I was on that stuff. I wrote a blog post about this once at the very beginning of my blog - the commercials for cymbalta are always very enticing because they talk about relieving the pain of depression (they've changed the commercials in recent months from "depression hurts, but you don't have to" to "depression hurts, but cymbalta can help" or something like that - and I can't figure out why...), and I wish I could've stayed on it longer to find out if it did actually relieve more of my physical pain, but it was really doing a number on me between the increased anxiety and crying jags. I also had a lot of trouble sleeping while on it.

The only other straight-up antidepressant that I've tried is the MAOI parnate, and that was for headaches, too. I actually came off pamelor and prozac to go on parnate. Even though I'd decided to come off prozac, it actually took me a number of months to get off it - every time I'd come off, I'd go back on and eventually when I knew I had to come off to try the parnate, I finally got off it. Nardil is prescribed more frequently for migraine than parnate is, but the psychiatrist who works at the headache center felt that parnate has some effects that are supposed to increase concentration, so that would be the better med for me, since I was also coming off (I think I had to come off this? Now I don't remember...) twice a day of concerta for ADD, which was really memory/concentration problems from topamax and now is just ADD. (I'd always had symptoms of ADD, even prior to needing meds...)

The thing is, a lot of times I feel like I wish I could take an antidepressant. First off, I wish I could try Yaz or any birth control, but especially that. Now, I'm not getting my periods because the domperidone (motilium) dose I'm on has increased my prolactin level and stopped me from ovulating, and the only way I get periods is by taking 7 days of provera. So the first reason I wish I could take birth control is because I would like to have regular monthly cycles (yes, I WISH I got my period!), but the other reason and the reason I'd like to try Yaz is because THE most depressed I feel, it is always magnified to the nth degree before I get my period/during when I have it. They say it helps with that. I can't take birth control because of having a history of blood clots, unfortunately...

So that is one of my worst periods of depression, but in general, I really wish sometimes that I was on an antidepressant because of how deep my depression gets. My psychiatrist seems to be for medicating as little as possible, which I actually agree with. But he seems to want me off almost all meds at all - and I've never asked him if he would prescribe an antidepressant for me because he worked so hard to get me off the tangled mess of meds I was on for headache prevention and to simplify my meds list. He even seems to question or maybe dislike it when I go to outpatient infusions when the headaches get really bad, and when I recently restarted verapamil for an increase in cluster headaches. He has prescribed meds for ADD for me, but never prescribed anything at all for depression or anxiety. I feel like he would prefer me to just continue to work in therapy (even if it meant increasing the frequency that much more - I already go twice a week, although was going 3x/week at one point) and keep pushing forward without meds...almost as if meds would be some hindrance or false crutch that would prevent me from truly experiencing therapy and the true weight of my emotions. Thing is, I'm fine when I'm in the sessions - even though I do cry a lot and am often anxious - but I've said to him that it's very hard to dredge up these things that depress/scare me and then be on my own the rest of the week. Two hours a week, therapy serves in a way as an antidepressant, but what of the rest of the time? This is a very long and drawn out process, so it seems, and I have invested quite a bit into it, but he's not promising that I'll feel better tomorrow, or even next year - just that the ultimate goal is that I will feel better - make better choices, and so on. But what am I supposed to do with the often deep, complex feelings of depression while I'm waiting for therapy to "work"? It's a rhetorical question that I often struggle with.

The other issue with SSRIs and me is that, due to cluster headaches and the constant migraine, I take triptans (amerge and frova) very often. Ordinarily, triptans would be restricted to twice a week, but with cluster headaches, this is often not possible as each attack is a severe emergent incident in terms of level of pain. Amerge and frova, while they take a long time to work, often prevent future attacks for occurring for several hours, and prevents (though I've recently started back on verapamil) don't seem to do a ton to stop the frequency of attacks. I really have not read up on the whole triptans/SSRI contraindication to find out if this is something that can be worked with if closely monitored, but that stands out as yet one more hurdle for my even trying them.

Final comments before I finish. Personally, if we ever did revisit the idea of my taking an antidepressant, I would not want to take paxil. Even the remotest risk of lightning zaps to the brain deters me - I have enough headache problems as it is. Which reminds me of the other complicating fact - why is it that every drug always has the side effects of headaches?? How do I know if I'm getting headaches from the drug or if it's simply not helping! Frustrating! Zoloft has always seemed like one I would like to try, but probably never will!

I know this is way too long (and I hope I have not divulged too much - I've always been pretty open about my headache history and ups and downs!), but this complicated jumble of thought is the reason why I did not vote in the poll!! I have no favorite SSRI, although the only one I ever took anyway was Prozac, unless you count SNRI Cymbalta. I don't know what to make of it. I would very much like to try an antidepressant, but don't think my psychiatrist would want me to (odd - seeing as it seems most psychiatrists DO want to prescribe meds in many cases, instead of being a very avid advocate for NOT prescribing meds, even though I definitely have an active diagnosis - but I know I'm a bit of a more complex case with having been on so many different things for headaches...), and I think my other medical conditions/meds I have to take also complicate the issue of my taking an antidepressant.

Stimulating topic, as always!!

Take care,
C :) (Like not typing out my name or using my usual identity makes me any more anon!! My story is fairly unique in many (but not all) ways! haha)

Anonymous said...

Zoloft - made me nauseated.
Paxil - made me feel disconnected and people at work were always askign if I was okay.

Prozac - I felt great, no longer sluggish every morning, felt socially comfortable, but it made me anorexic and when I got down to 98 pounds I had to get off it. It also eliminated my sex drive.

Next was some SSRI that I think started with an "R" and which made me eat or think about eating all the time.

Effexor - made me warm and one winter I never wore a coat or sweater. When the weather warmed up my dr switched me to Celexa.

Celexa till Lexapro came on the market, several years on Lexapro. It has caused me weight gain so I'm thinking about talking to a psychiatrist about trying something else. My internal med dr prescribes my Lexapro but doesn't want to do anything complex.

Anonymous said...

I hate to be one of those people that just "drops in" to ask a question, but here goes...In your experience how long did Paxil withdrawal last? I stopped Paxil about a month and a half ago. I had tried weaning off of it in thepast and it was HORRIBLE, so this time my MD suggested just switching to Prozac (b/c of the longer 1/2 life) and slowly tapering that. I am now at two weeks on nothing. I felt fine for the first week on no Paxil and just Prozac, but on day 8 the hell started. Horrible vertigo, nausea, HAs, the "brain zaps", etc. All food makes me very nauseated and all I can do is lay in a dark room and try and convince myself I'm not going to vomit. I'm also very weak and lightheaded. It may be marginally better in the last few days. I was ok and just figured I would cope - it couldn't last forever, right? Then I read on-line it could last SIX MONTHS!!! Is this accurate?