Elizabeth, 64, a former lawyer in Ontario, Canada, had taken the antidepressant Celexa for two decades. It helped her cope with the stress of being a full-time caregiver for her two sons, who are autistic.
But last year her medication wasn’t working very well. Her sons, now both in their 20s, are still at home, and she was feeling burned out.
“I would find myself putting dinner on plates at night and just like, ‘I can’t do this anymore,’” said Elizabeth, who asked to be referred to by her middle name to protect her family’s privacy.
Her primary care doctor advised her to wean off Celexa over the course of a few days then immediately switch to Zoloft, another type of selective serotonin reuptake inhibitor, or S.S.R.I.
Soon she began developing psychological problems that she had never experienced before: continual crying, hopelessness and suicidal thoughts. She also experienced a tingling pins-and-needles sensation in her face, decreased appetite and heart palpitations.
I was “a mess of a person,” she said, who “saw no hope.”
Eventually she consulted with various psychiatrists, one of whom recognized the problem: Elizabeth had most likely developed “protracted withdrawal” from weaning off her original medication too fast.
When it comes to switching up an antidepressant, “there is a terrible lack of guidelines” to help doctors and patients make these decisions, said Dr. Stephen M. Stahl, a professor of psychiatry and neuroscience at the University of California, San Diego. Not every doctor receives the same type of training to determine the best possible path, and some “just do it willy-nilly,” he said.
If you and your medical provider are thinking about changing your antidepressant, here are some things to keep in mind.
You may not need to switch at all.
If you’re tolerating a drug well but it isn’t as effective as you had hoped, doctors should first consider whether the initial dose was appropriate, said Dr. Nina Kraguljac, a psychiatrist at the Ohio State University Wexner Medical Center and chair of the American Psychiatric Association’s council on research.
Adjusting a patient’s dose slightly might do the trick, she said.
It can also be effective to take two antidepressants at the same time, or to try an add-on treatment, which are additional medications that can help the initial prescription work better. Commonly prescribed add-ons are bupropion and aripiprazole. Newer options include lumateperone and cariprazine.
You can also add psychotherapy to the mix, experts said.
Sometimes doctors add on multiple medications — as many as five or more — for patients with especially complex cases. While it might be necessary, the practice is also risky and may come with difficult side effects or potential drug interactions.
Doctors should regularly review these additions and ask: “Should I be stopping this?” said Dr. Stahl, who is the co-author of a guide that explains how to help patients stop or change their psychotropic medications.
‘Cross-tapering’ is widely considered best practice.
Sometimes, however, it is necessary to make a switch.
A patient might have intolerable side effects such as sexual dysfunction, weight gain, emotional numbness, fatigue, insomnia or gastrointestinal issues. In other cases, the drug just isn’t working. Research suggests that only about one-third of people feel better after trying their first antidepressant.
Assuming that physical problems like hypothyroidism have already been ruled out, trying a different antidepressant may help.
Dr. Karinn Glover, an attending psychiatrist at Montefiore-Einstein Psychiatry Associates in New York City, said she does not typically take someone off an antidepressant completely and then start them on a new one. Instead, she does something called “cross-tapering,” usually over the course of three to six weeks.
That means gradually reducing the dose of the original medication while the new medication is introduced to the body.
Dr. Glover was taught to go slowly, be mindful of potential side effects and maintain communication with the patient weekly to see how the switch was going — “even if it’s just a message over MyChart,” she said, referring to a widely used patient portal in U.S. hospitals.
The goal is to maintain symptom relief while minimizing any discontinuation symptoms, she said.
Many psychiatrists consider this method to be ideal, unless a patient is currently taking a S.S.R.I. and switching to a monoamine oxidase inhibitor, or MAOI, an older type of antidepressant. The S.S.R.I. needs to be fully removed from the system before the MAOI is introduced.
Watch out for problematic symptoms.
Approximately one out of every three people report withdrawal symptoms after lowering a dose or stopping an antidepressant. These can include flulike symptoms, brain zaps (or disorienting shocklike sensations in the head), insomnia, nausea or vomiting, and sensory disturbances, like the tingling sensation that Elizabeth had.
Some patients, like Paul, 47, who lives in New York City, may also develop severe anxiety and restlessness.
Paul, who asked to be referred to by his first name because of the stigma associated with long-term mental illness, switched from Effexor, a drug he had taken since his early 20s, to Lexapro in the hopes of having fewer sexual side effects.
Soon after he felt as though his body would not relax. He said he developed “unbelievable anxiety” and wanted “to tear my skin off.” His doctor quickly took him off the Lexapro and put him back on his original medication.
It’s important to tell your doctor right away if you experience any symptoms while in the process of stopping or switching to another drug, experts said. Your doctor might decide to have you taper off more slowly, or increase the new medication at a faster rate.
Finally, patients should always be transparent about which medications they are already taking. Physicians need to be aware of potential drug interactions that can lead to serious problems, like a rare but potentially life-threatening condition called serotonin syndrome.
As for Elizabeth, she found some relief in January when her husband retired and was able to help out more at home. At the advice of a psychiatrist she weaned off the Zoloft, which wasn’t agreeing with her, and switched back to the same dosage of Celexa that she had used for 20 years.
Although she still has some tingling sensations in her face, her other symptoms have disappeared.
Last year “just about broke me,” she said. “But I’m feeling so much better.”
Christina Caron is a Times reporter covering mental health.
The post What to Consider Before Switching Antidepressants appeared first on New York Times.
