Confused! 2 GPs, 2 views on changing from Prozac to Mirtazapine.

[piratecat]

Hiya, long one I fear, but please plough through of you can!

(my)GP one, told me swap from 40mg Prozac to 15mg Mirtazapine overnight.

Took the new one in the evening, felt drowsy within half an hour. Woke this morning totally spaced out and struggling to compute. Still don't feel undizzy now.

Rang surgery today and was lucky enough to speak to duty doctor (old school guy been there for donkeys) who said don't take another one tonight, take 20mg Prozac tomorrow and review in two weeks.

Is it normal to swap directly from one medication to another anyway, without withdrawing as my original gp said to?

backstory- having been on Prozac succesfully at 20mg for 5-6 years I had major mental trauma start of the year, and went downhill sharpish. Prozac upped to 40mg, but it's made the anxiety worse, or maybe I am just worse generally after the 'breakdown of sorts'.

After/during this bad bad time was looking for something to help the panics etc... so (my) gp firstly suggested Citalopram. I took this for a few days. She asked me if i felt any better, and i said no not at all, then she said it's not working then.
Surely it would have taken longer??

So anyhow, this same gp is the one who has told me to swap directly from Prozac to Mirtazapine yesterday, bang bang.

Feeling she is not good with this.

thanks for letting me go on, just a bit confused on top of it all. Would appreciate any info or experience of swapping, timings etc.

x

i am not giving in!

I'm sorry I can't give any info about changing from one anti depressant to another. But have been put on Mirtazapine 15g, and have been taking it for a week.
After the first night I was so groggy I didn't think I could cope with it at all. However I've persisted and found that I get relaxation and sleep, which for me is amazing, and the grogginess is there in the morning but soon goes when I get up and seems to be less.
For me it's worth persisting, it's so difficult to find medication that is right for us. The sleep is what I personally need so I can deal with my issues and can only hope my mood lifts soon.
I hope you get more information from others re: the meds changeover.

hello bluebird thankyou.

can i ask were you on another med b4 or have you been put on this one straight off.
After i had taken it at 6 in the evening by 7 i was dizzy and ready to drop. Did you feel anything like that, or just tired?

So sorry piratecat - have I got this right - that you had a relapse at the beginning of the year because of a life event, and this is when you started going downhill.......I'm sure you know the meds cope with the symptoms of our depression but not the underlying reason. Has there been any resolution to the problems you had earlier this year. If not, have you thought of getting some therapy to help sort things out in your mind.

To be honest I don't think the average GP knows very much about mental health at all, and I think there is a lot of guesswork attached to their prescribing. I think it's all trial and error with ADs and that makes things very difficult for us sufferers.

I am no medic but I suspect that an abrupt change from one AD to another is unusual.......I think one is usually tapered off before the change to a new med. I think when 2 GPs disagree with each other, that leaves the patient not knowing who is right. I can't understand why any GP would expect a patient to feel benefit from any AD in a matter of days. Conversely they usually stress that ADs can take 2/3 weeks to "kick in" - I would have no confidence in such a GP.

I am on an old fashioned tryclic AD imipramine and because I have been an inpatient on a psych ward following a relapse of a severe depressive episode, I am "fortunate" enough to be in secondary, rather than primary care, and so I get to see a psychiatrist and support from a CPN. After an awful Jan and Feb this year, the psych added mirtazapine to the imipramine, initially at 15mg, then 30mg and then in Sept at a follow up appt he asked if I would agree to 45mg mirtazapine, and I agreed to this. I don't have any particular side effects other than feeling sleepy but this is an asset really.

I think you need to book a double appointment (not with the GP who changed the meds) and discuss your meds and tell them you are confused as you have 2 GPs telling you different things.

Hope things get sorted - it's a torment of an illness isn't it....

Yes it can be normal to swop between two depending on what tablet you are on. Mirtazapine is a sedative ad. Agree, book an appointment with the dr you spoke to on the phone and talk through medication options.

Perhaps the Prozac and a short term extra anti anxiety medication is an option to discuss with them?

Hi PC, I am sure I have talked to you before on a fun thread when I was BobblyGussets, but anyway, I am on 40mg Prozac. I wouldn't like to be swapped like that. Did the GP give you good reason why?
Not much helpful to add, I just wanted to empathise, and to echo what NanaNina said: SSRIs do have a long half life, and do take 2-3 weeks to have a positive effect, so I wouldn't say something like Citalopram would make you feel better after a few days.

I had what I would call a "life event" too at the beginning of the year; I had never had someone I truly loved die before and my lovely Nan passed away in Jan (surrounded by people who loved her, thank fuck). I have never cried so much in my life. Apart from feeling that I want to cancel Christmas this year, I am getting on fine. I hope you are ok.

Do you have the option of just giving in to the drowsiness until you get used to it, or do you have a busy job/young children?

hi thankyou for your advice and experiences.
the trauma was a break up that brought up alot of stuff.
i have been waiting to see a psychiatrist for months to get me onto better meds. i am also on the waiting list for counselling.
am not sure what groups my prozac and this new one are in with regards to swapping over.
one doc has one way the other who isn't mine so i can't actually see him told me to stick to original med but go lower.
this doctor of mine does have form for indecisive advice but i have to stick with her as she knows my history and i am trying to go to a tribunal to get financial help ie the old incapacity ben.

Mirtazapine is one of the few antidepressants that you can take with some other antidepressants so there shouldn't be a concern about you starting it straight away. Some people end up on both Prozac and mirtazapine. There is a very small increase in the risk of a very rare side effect called serotonin syndrome but your symptoms don't sound like that and one day would be too soon in all likelihood. Prozac has a very long half life of several days (and takes several weeks to completely come out of your system) which means that if you suddenly stop it you still should find it will gradually come out and is far less likely to cause withdrawal effects than other antidepressants. Again one day of missing it is unlikely to have caused the side effects you experienced. On the other hand some people do still experience withdrawal so there is an argument to going down to 20mg and stopping it in a couple of weeks even whilst continuing tge mirtazapine. Basically it sounds like it's the initial effects of the mirtazapine you've been experiencing. You may well find they settle if you carry on taking it. You are right about the citalopram, you wouldn't expect to conclude it doesn't work in a few days though some people are lucky and there is increasing evidence people see effects of antidepressants sooner than was traditionally thought.

thankyou so much for that post it was really really informative.
i am glad to hear of the shelf life if i may call it that of the prozac in the system.

So it was the effect of the mirtazapine. I Ido question my doc because there is always a tendency with her to ask me what i want to do and i know less than her.
i have an important two weeks coming up and need to think clearly without the fog yet i know my sleep is also important.
what to do next. maybe take another tonight.

also i don't think anything would have helped my symptoms when doc concluded the citalopram not effective.
i had developed a disasoiative disorder and could not speak on top of feeling i was in a dream.
it came on so fast and lasted two weeks or so. very upsetting.
i really need to see this chap the specialist. x

Yes, sounds horrible. Dissociative symptoms can be extremely unpleasant. Sometimes antidepressants can help dissociative conditions a little though you are right they either tend to resolve by themselves or with psychological therapy or more basic practical measures like OT/physio/focus on making positive life changes etc
It does sound like it isn't a straightforward depression iyswim. Most if not all depression benefits from combined treatment with basic practical and support measures and sometimes psychological work in addition and I suspect you are right in that ads will only be part of the answer for you.

If I recall correctly mirtazapine comes as an orodispersible tablet and I think you should be able to cut it into smaller pieces. You could try taking a half dose or even smaller and build up gradually? That sometimes helps. Also for some reassurance the higher doses sometimes have a weird paradoxical effect when it comes to side effects and in some people get better at the higher dose rather than worse. It can be a good drug for people with atypical depression so it's not a bad one to try.
Hope things improve for you soon :)

once again thankyou. are you a doctor?

i had researched the mirtazapine and read about 30mg having less side effects.
my gp did mumble something like see how you get on and you can take more if you feel you need to.

Yes, I'm a doctor. :)
If you do end up finding the mirtazapine manageable, do go up to 30mg. That's the minimum effective dose not 15mg, though 15mg is fine for combination therapy with other antidepressants.

Hi I found it took a few weeks for mirtazapine side effects to wear off.

Whilst psychiatrists can be helpful regarding mental health diagnosis and medication the one I last saw said " so what medication do you want" and I am here for you to consult - so not helpful!! As they said some conditions need time, changes in lifestyle, practical measures as much as medication etc. and medication takes a while to work in some cases.

Hope you find a regime that suits you, but a few weeks into medication side effects can go. The second line ad's that are used if others do not work ( like mirtazapine) can have stronger side effects for some people.

I couldn't get on with mirtazipan at all.

I felt drunk in the evenings and like I was swimming through treacle the next morning, until about lunchtime.

I've previously had Prozac which was great but made my hands so shakey (I work with students so a big no no)

I then had sertraline which made my anxiety 10x worse and had me craving alcohol the minute I work up (weird)

I've now been on citalopram for 10 days and feeling good so far.

I hope you find something that works for you soon

Xxxx

Yes, I found sertraline the best for me, no or little side effects and works. The psychiatrist said if she was ever mentally ill that is what she would want! But different things suit different people

Yes that's so true HH that "different things suit different people." I think this is what makes mental illness so damn difficult that what suits A doesn't suit B and what helps in one episode of depression might not help in a further episode. I did comment to the psychiatrist on a follow up appointment in Sept that "it was all trial and error with ADs" and he seemed a bit tetchy about my comment and said the same was true of all sorts of physical conditions too, and I hadn't realised that. Still not sure that's the case.

It's interesting that we have a Dr on the thread Elarmarama and I'm feeling a bit embarrassed as I said upthread that I thought GPs didn't know a great deal about mental health, but of course this was just my own experience, so it wasn't a fair comment.

Don't worry Nana! I'd agree, some GPs know a lot but some very little about and have very little interest in mental health issues which is something I don't understand as it's such a large part of primary care. The GP trainees in our area at least now have to do some psychiatry in their training which is long overdue in my opinion. I'd also completely agree with you about different things suiting different people and it all being trial and error. In fact there are studies showing exactly that. Look up the STAR*D trial if you're interested which was a big trial looking at treatment strategies in treatment resistant depression and really showed that no one option was better than any other.

Hi, I used to be on Prozac AND mirtazapine at same time - in fact was told that combination was best at time - so there shouldn't be any issues with them "interacting" in a bad way. Mirtazapine worked well for me for about 6 months but then stopped and now I'm on Agomelatine and Prozac and this has worked better for 2 years now. Still have lots of ups and downs but not ended up in hospital for 2 years

hi what time is it best to take the mirtazapine.

Thanks for the info Elarmarama and I will look up the trial that you mention. I was seeing a psychologist before my relapse who had done her PhD on mental health. Her book was called "Helping people come off Prescribed Medication" or something very similar. I had been on imipramine for 15 years since my first episode of severe depression and 3 months as an IP, following the death of my closest and dearest friend at age 46.

The psychologist certainly knew the right way to get me off imipramine, and was the first person to mention withdrawal symptoms. I had tried on 3 or 4 occasions to come off them in the past (twice with the oversight of 2 different GPs) and had a rapid return of the symptoms of the initial depression, whereupon GPs had told me I must go back on the meds and not try to come off them again. There was no mention of withdrawal symptoms, which of course was what I was experiencing.

During the months that I saw the psychologist on a private basis I was on 100mg imipramine, and she advised that I reduce very slowly and stressed that I must feel in control of the process which was important to me. She asked me what I would be happy doing and said she would only stop me from reducing too quickly. I decided on 10mg per month and she advised that I may feel slight withdrawal symptoms but I would know why they were occurring. She said missing a month if I wanted to was fine - in the end I did reduce 10 mg a month and I was off them in 10 months but within 4 months and some life stresses I relapsed and again was an IP for 3 months in 2010 but have not made a complete recovery this time. I am around 80% ok and 20% bad or mixed days.

This psychologist (whose orientation was psycho dynamic) was firmly entrenched in the psychological model and would have no truck whatsoever with the medical model. She often told me that there was no evidence to prove that there was any change in brain chemistry in depression, and that in many trials it had been proved that placebos were as effective as ADs. She once gave me an article to read by a consultant psychiatrist (Joanna Moncrieff) I think was her name and she was putting forward this theory, and stating that many GPs also believed this but prescribing meds was the easiest thing to do. I wonder if you could comment on this Elarmarama as I would be interested in your view.

I didn't think mental health was covered in any depth in the GP's training but from what you say about GP trainees, it seems that psychiatry was not covered at all in the past. I did hear that one third of all consultations with GPs were related to mental health issues. I don't know how true this is or whether there are regional differences.

Hi QofC remember you from other threads and so glad you have not needed hospital admission again, something to be avoided at all costs!

Piratecat I take mirtazapine before bed as it zonks me out pretty quickly and ensures I stay asleep all night!

Pirate - in the evening. Most people take it before bed but again sometimes taking a bit earlier can mean you feel more awake the next day. Again, a bit trial and error.

Nana - sorry to hear of your difficulties. All GP trainees have some psychiatry within their GP placements but only a few would do 6 months just doing psychiatry within a psychiatry dept. Now they all do. 1 third is accurate I should think though many estimate higher. Physical presentations like dissociative disorders are probably massively underestimated too.

I agree to a certain extent with your psychologist in that for mild to moderate depression then there is very little if any difference from placebo, prob for many many reasons. Many people would do better with psychological treatments or both than antidepressants alone. However access to decent psychological therapy is not easy so GPs often have little option but to resort to them. For severe depression then there is a clear difference between antidepressants and placebo. Many of those patients are in no position to have psychological therapy as they are too ill to concentrate for enough time yet they do get better with biological treatments. There are many studies showing there are biochemical changes. Anyone who has seen someone with a depression so severe they literally cannot move or even drink suddenly talk and smile hours after ECT would be in no doubt that there is something in the medical model. Like many things it's probably a combination and an interaction between both.

thanks, i took my one at six and by 7 i was zonked, and spaced the next day till mid morning.

have been readin it causes alot of weight gain, or at least it increases appetite. that's a concern as i have fought hard to lose two stone the last yr. i am now in the normal bmi range