I am a 48 year old male and I have been on Paxil for about 11 years now and have been wondering about getting off it. I am aware that there is “detox” time needed and I’ll feel like shit (among other things), . . my question is: should . . . → Read More: My, Oh My, How Time Flies!!! Getting Off Antidepressants After Accidentally Taking Them For A Decade]]> Mike writes in with a frequently voiced concern:

I am a 48 year old male and I have been on Paxil for about 11 years now and have been wondering about getting off it. I am aware that there is “detox” time needed and I’ll feel like shit (among other things), . . my question is: should I get of the meds or is this something that I’m going to need for life? Or any other options?

Realize, of course, that I know nothing about your past history or why, at some point, some doctor (shrink or family doc) decided that you needed something to make life better.  And you were feeling lousy enough that you went along with the idea AND it MUST have done SOMETHING.  Cause here you are 11 years later still on it.  The missing component here, of course, is follow up.  Somewhere along the line this question should have been answered for you . . . like nine or ten years ago.  But here you are now, on the med for a decade and not sure.

As I see it, the worst case scenario for you is for you to go off, and have a return of the symptoms that caused you to go on it in the first place.  Since Paxil is most often used for Major Depression, anxiety or that difficult mixture of both . . . that is what could come back.  There is no way to know for sure if it will.  Statistically speaking, people who have had multiple episodes of depression/anxiety are more likely to benefit from long term use of antidepressants.  If, for example, you have had three episodes of depression since high school . . . go off the meds and you are likely to have another one.  Not 100% likely . . . but a high probability.  For some, going off the meds is worth the risk.  For others it is not.  If you had a single bout of depression/anxiety eleven years ago and you accidentally stayed on Paxil ever since, you absolutely deserve a try off the meds.  You still have a higher chance of getting depressed/anxious than the average population (cause you had it once), but I typically encourage a try off at some point if there has been only one episode.

The process of getting off is the sticky detail here.  It sounds like you have heard some of the horror stories of Paxil withdrawal.  We don’t actually call it “withdrawal” . . . we call it “discontinuation syndrome” . . . because it sound soooooo much better than withdrawal.  Discontinuation syndrome can happen with almost any antidepressant.  It is a very uncomfortable mixture of physical symptoms such as brain zaps (if you have ever had them you know what they are), light-headedness, and weird visual-perceptual issues.  None of them are life-threatening.  It just feels bad.  And it can last for weeks.  There are two solutions to this problem.  First, go down very, very slowly.  The initial decreases are usually tolerated well.  It that last 5 or 10 mg that can be difficult.  In the past, I have had patients quarter their 10 mg tablets and take 2.5 mg four times daily for a month or two . . . then three times daily for a month or two . . . then twice daily . . . get the picture?  The other way to get around discontinuation syndrome is to do a rapid substitution of Prozac for the Paxil.  Once you are sure things are stable with your mood/anxiety, taper off the Prozac.  They hit the same receptors and the risk of discontinuation syndrome with Prozac is zero.

Bottom line is that that fear of withdrawal should not be the deciding factor in getting off Paxil.  It should be a clinical decision based on your risk of having a relapse in the symptoms the medicine treated.  Of course, that decision should be made with a treating physician.  A psychiatrist is better than a family doc because of the experience factor, but it can be hard to find a good shrink.  Hope this helps!

–Dan Hartman, MD

I have been taking 100 mg of Lamictal for about two years. In the last 1.5 yrs my doctor added 100 mg of Pristiq. I have recently lost my health insurance and need to get off both drugs as a result. How should I do this? I’m a full time student and a mother . . . → Read More: Another Casualty of the Lack of Health Care Reform]]> Andrea writes in:

I have been taking 100 mg of Lamictal for about two years. In the last 1.5 yrs my doctor added 100 mg of Pristiq. I have recently lost my health insurance and need to get off both drugs as a result. How should I do this? I’m a full time student and a mother of 2 children. When I miss a single dose of either drug I become ill. Nausea, dizziness, irritability, etc. I can’t afford to fall apart but I can’t pay for the drugs any longer. Please advise

Ok, I’ll get down off my soap box and tend to this practical matter.  But, really, when are we as a people step up to the plate and not allow this to happen.  If someone needs medical attention to continue to be a productive member of our society, how can we look the other way???

Ok, some practical advice . . .

I know nothing of your history.  There are two issues going on here, tho:  1)  how do you stay on the medicine (or some medicine) and keep your self going;  and 2)  how do you get off of you don’t need to be on medicine.  The answer to that question comes best from your conversation with your health care professional who is prescribing the medicine.  If you need to stay on the medicine, then you either use samples (Prisitq still samples), go to the manufacturer for freebies (they have patient assistance programs . . . just go on to their website and look around), or switch to another medication that still comes in samples (in my neck of the woods, Lexapro and Cymbalta are still aggressively sampled).  If you NEED to be on medicine, the question is how to get you some medicine in a way that you can afford NOT how do I get off so I am not so uncomfortable when I crash.

If you are able to get off the medicine (again, that decision should be reached with your health care provider), you should talk to him/her about how they will get you off.  For my patients, I subscribe to the philosophy of slow being better.  While Lamictal is not too bad for most people to get off (although you will read horror stories on this site).  I would go down by 25-50 mg every two weeks or so until you are off.  As for the Pristiq, I would again go slow.  Remember, the core molecule of Pristiq is a relative of Effexor . . . one of the more difficult medicines to get off.  It will be typical for you to have discontinuation symptoms as you come off Pristiq unless you go slow.  I would drop by 25 mg at most every two weeks or so.

My biggest concern  here is that you seem disconnected from the health professional that has been prescribing this medicine.  I would get in to see that person and tell them about what is going on with you.

Good Luck.

–Dan Hartman, MD

I love you, baby, can I have some more,

Oh, the damage done.

I hit the city and I lost my band,

I watched the needle take another man,

Gone, gone, the damage done.

I sing the song  because I love the man,

I know that some . . . → Read More: . . . Another Man Done Gone . . .]]> I caught you knockin’ at my cellar door,

I love you, baby, can I have some more,

Oh, the damage done.

I hit the city and I lost my band,

I watched the needle take another man,

Gone, gone, the damage done.

I sing the song  because I love the man,

I know that some of you don’t understand,

milk blood to keep from running out.

I’ve seen The Needle And The Damage Done,

A little part of it in every one,

But every junkie’s like a setting sun.

–Neil Young

I first met him when he was eleven years old.  That was October, 2001.  I don’t remember that meeting specifically, but, over the years, I met with him and his family enough to form a lasting relationship with him.  He was a smart boy who struggled with focus and concentration and self-confidence.  It was difficult to find that sweet spot with the medicine.  You know, the spot where the benefits out-weigh the liabilities.  Because of that there were many shifts in medicine over the years and periods where he was on no medicine at all.  But he would still come in with his mother and father and his brother, who were also under my care.  Even tho my time with them was always brief, I have always had a sense of great connectedness with this family.  Their visits always ran long as we discussed not only the standard medication issues, but how the family was doing and how each felt.  We would discuss matters of spirituality and traded a movie and a book.  His parents were kind, gentle and thoughtful people.  He came by his nature honestly.  As he grew, he reminded me of one of my good friends I grew up with.  Thin face with long hair and a quiet deliberateness to how he spoke.  He was smart, but a bit stymied by his ongoing attention and impulsivity issues that made “success” elusive for him.  But at his core, he was a kind and gentle young man.  In that way, he reminded me of my own son.

As too often happens, his difficulty fitting in to the standard mould led to his entry into a counter-culture peer group.  He slipped into smoking pot and who-knows-what-else over the years, finally ending up addicted to heroin.  He would go through times of sobriety and relapse, feeling overwhelmed by the lure of effects that the drug offered.  He had difficult separating himself from those who he did drugs with.  He was always trying to help someone and save someone . . . but this often ended up dragging him down again.

And his parents . . . his poor parents.  Struggling as they were with health issues and difficult financial times caused by the recent recession kept trying to do the right thing.  Do you throw him out?????  Do you keep him in?????? What is the right thing to do?????

There was no right thing to do.

He knew he was loved.  He knew who cared for him.  He knew he was in trouble.  He knew, intellectually, all that had been taught to him over the years by his mom and his dad and by all the adults in his life.  No one did anything wrong over the years we tried to help him.  But, in the end, we couldn’t save him from himself.  Sullivan was found dead of a drug overdose a couple of weeks ago.  Perhaps, his mom related, the “one more high” before really going sober.  He seemed so close to kicking this habit.  But, now . . . he’s gone.

Sometimes when I lose a patient, I feel angry.  Today, I just feel sad.  Very sad.  The world . . . my world . . . was a better place for having known him.  The world will never know what was lost here.  His kindness and gentleness and intellect is something that the world needs more of.  Who knows what he could have done to help us all.  My heart goes out to his mother, his father, his brother and all of the extended family.  Keep them all in your thoughts and in your prayers for as long as you can remember to.  It was from them that this kind and gentle man came into the world.  It was under their care that he developed into the wonderful man that he was.  They did all that they could to get him back when he veered down this difficult path.  They are good people.  They were good parents.  Sometimes tho, despite our best efforts, our children choose a difficult road.  I hope to continue to be part of their lives.  The memory of their son will always be part of mine.

Another man done gone . . .

Another man done gone . . .

Another man done gone . . .

Dan Hartman, MD

The first step, of course, is to make sure that you . . . → Read More: Making Effexor more Effective for depression and anxiety]]> Anne writes in . . . (I) am currently taking effexor. effectiveness marginal. still depressed and still anxious in social circumstances, perhaps, I just need more time with that aspect. what, if any other drug might I combine with the effexor to help with the depression?

The first step, of course, is to make sure that you are taking enough Effexor.  As you may know, Effexor acts as an SSRI at lower doses but does have some norepinephrine action at higher doses.  If you can tolerate it, your dose of Effexor should be pushed up to 300 mg daily (some docs push even higher).  If, after two months or so, that is not being effective for your depression/anxiety, it is not likely to.  As for your anxiety, you should (OF COURSE) be in with a therapist who is working on behavioral management of your anxiety.  What works best for that is a good primer on managing anxiety with relaxation techniques and then exposure to stressful situations where the anxiety techniques can be practiced in real-time.  That is much better than relying on anti-anxiety tranquilizers like the benzodiazepines (Xanax, Klonopin, etc.).  As for your depression . . . YOU SHOULD ALSO BE IN THERAPY FOR THAT . . . needless to say . . .!  Medication-wise, if the dose of the Effexor has been maximized, but not effective, you can either change medications completely (the next choice would depend on what you have been on in the past) or augmentation.  The first agent I typically use to augment an antidepressant trial is Wellbutrin.  Combining Wellbutrin with other antidepressants is well accepted at this point and often quite effective.  It makes sense because of the complementary mechanism of action it has when combined with other antidepressants.  Other augmentation strategies that would make sense in someone with significant anxiety include the addition of lithium or Abilify.  You should also taking appropriate dietary supplements to make sure that your brain is optimized to accept the help that the medication has to offer.  At the very least, I would recommend fish oil, vitamin B12 and vitamin D.  Talk to your doc about those as well.

–Dan Hartman, MD

“NOW!!!!”

Oh, that it was so easy.  The above question is misplaced, however.  Over and over I meet with patients who are on various medications that are shifted and moved and changed and what not.  Waiting . . . → Read More: Waiting to get better . . . What are YOU waiting for???]]> ” . . . . soooooooooo doc . . . when is this medicine going to kick in . . . ?”

“NOW!!!!”

Oh, that it was so easy.  The above question is misplaced, however.  Over and over I meet with patients who are on various medications that are shifted and moved and changed and what not.  Waiting and waiting.  Watching for some signs that THIS is the ONE medicine that will FINALLY make the difference and all will be healed.

Oh, that it was so easy.

Beyond a doubt, the most frustrating aspect of having AND treating emotional illness is how it saps your resolve to make things different.  The hope that is placed on medication is mis-placed.  Not that medication does not have a role in the healing process.  It does.  But to put those little pills in your mouth and then to go wait for life and circumstance to improve is  a recipe for failure.  I certainly see it in many of my patients and many of you out there are living it.  You may have stumbled upon this site looking for advice on that ONE MEDICINE that might do the trick and kick in and make life FINALLY better.

I hate to be the bearer of bad news . . . but that is rarely how it works.  Or IF it works that way, there is often a slow and gradual return of symptoms that is disheartening and frightening.

The bottom line is that if you want your life to be different and you want your moods and emotions to be different, you have to DO things differently.  Living life the same way month after month, year after year, and then complaining that nothing is different is a bit circular.  How can things get different if you don’t become different.  How can life be better if you don’t do something to make it better.  Medication can have a significant role in helping you, but ultimately, YOU must make your life different.

So, what are you supposed to do?  How should I know . . . I don’t know you!!  I certainly don’t have some magic recipe for getting better.  We are all too different for healing to be prescribed in a cookie-cutter way.  There are basic guidelines that . . . ahem . . . you already know.  Yes . . . YOU ALREADY KNOW.

Like . . .

1.   Get a good nights sleep.  Yes that might mean taking some medicine for some who have sleep disorders, but it might also mean making some vvvveeeerrrryyyy scaaaaaaaaaaary changes in your life like . . . getting up early . . . taking the TV out of your room . . . keeping busy all day to tire your body out . . . cleaning all the clutter out of your room so that it is a positive environment . . . you know . . . all the things you already know you should do.

2.  Get some exercise.  That doesn’t mean spending a lot of money on a gym membership and trying to fit one more thing into an over busy life.  It means . . . go for a walk.  Do some light calisthenics . . . you know . . . like you learned in 6th grade gym class.  Lift some light weights (even a can of peas will do).

3.  Get some face time with nature.  Go for a walk in nature (see #2 above).  Go watch some birds.  Look for bugs in a dead tree stump.  Weed your garden.  Go have a picnic lunch under a tree.

4.  Work on your spirituality.  This takes on many shapes and forms.  Whether it means going to church/synagogue/mosque or it means taking a yoga class and meditating.  Getting in touch with that energy at the root of all creation is key to feeling better.  It is key to breaking out of our “I and how I feel are at the center of the universe” mentality.

5.  Go see a therapist and work on how you manage the stresses in your life.  I got news for you.  Just complaining about  how your boss or your spouse is jerk does nothing to make you feel better.  You gotta THINK differently about the various people in your life that “cause” you stress.  They don’t “cause” you stress.  How YOU think about them and what they do “causes” the stress.

Now . . . honestly . . . you already knew this stuff, didn’t you???

The medication that is prescribed can be helpful.  It is not THE answer.  Healing and health is an active process.  Your active involvement in the process is key to success.  Go make some changes.  Go do the things that you know you should be doing.  Go live life to the fullest.

–Dan Hartman, MD