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.

It's good to know Elarmarama that all trainee GPs will do 6 months in a psychiatry dept. There was a doctor (junior I suppose?) doing a 6 month placement with the Consultant Psych who admitted me in 2010. I thought that he had chosen that placement. He was a very pleasant young man and I had a lot of his time as I was the only patient on the ward admitted by the Cslt Psych who was overseeing his placement. Incidentally (the Conslt Psych) was a nightmare. He had no inter personal skills whatsoever and did not even make eye contact. All the nursing staff were wary if not afraid of him and reviews were a Q & A session between him and me, whilst the rest of the attendees could have been cardboard cut outs. On the one occasion when he was on holiday, and another psychiatrist chaired the review, the whole tenor of the meeting changed and others (ward staff, OT, etc) felt free to make comments.

Unfortunately I did not have the confidence to be assertive, although I did in the end write my own discharge plan as he was chopping and changing his mind about discharge. I still have a CPN who is lovely and over time we have got to know each other well, and she is someone who can stand up for me if necessary.

It's interesting that you mention ECT because I came across this when I was an IP in 2010 (on an older people's ward as I was 66 at the time) and I realised that patients were having ECT and was really shocked as I remembered those awful things we saw on TV some years ago with people shaking and writhing about. I was told it was nothing like that now and that it was a very effective treatment for drug resistant depression. I did actually see one lady change before my eyes. When I was admitted she was out of touch with reality, attempting to remove her clothes and making bizarre comments, and the staff were feeding her. I thought she had some form of dementia, but within a few days she was absolutely fine and we began to talk together. I asked her what her mental illness was, and she said "reactive depression." I later learned that if depression gets very severe, that it is possible to have a psychotic episode and this is what had happened to this lady. She had no memory of the time that she was out of touch with reality.

I agree that a combination of the psychological and medical model is probably best, especially for people who have some buried trauma, although many MNs talk of the success of EMDR therapy for trauma in childhood e.g. sexual abuse. I was fortunate in that I was able to access good psychological therapy on the NHS, with a psychologist attached to the hospital and specifically to the older people's ward. I had about 20 sessions but she went on maternity leave. My CPN told me that she has now returned to work and had offered to see me again. It was very helpful to talk with her about the death of my friend and the aftermath and how my grief got "stuck" so that even now, 19 years on I can still get very upset at times. However I didn't find it helpful in terms of managing my bad days any better. I think it is very difficult for people to understand the torment of depression and anxiety without first hand experience. It's difficult enough for those of us who suffer from it to have any real understanding, well that's how it is for me. Once the bad days have gone and I am "me" again I forget how bad it felt, but as soon as they return I remember of course. My CPN tells me that this is very common.

Sorry I am rambling a bit and I think I'd better stop as I am hi-jacking the thread and I think it's because we have a doctor on which is unusual. Finally can I ask what dissociative disorders are please?

Hi, hope you don't mind me butting in. My problem with mirtazapine was that i really, really put on weight

oh blimey, i thought so i really don't want to put on weight, i wonder why this particular med is being highlighted as having this side effect.

Surely i must be overeating? Or is it slowing the metabolism down, and if you're eating healthy it's not registering?

I have some amitryptiline which was prescribed way back and took one last night for sleep, but i woke up quite a few times. 10mg.

Elamarama, would you prescribe this for sleep help and anxiety ?

I'm a GP with an interest in mental health. In the past I've been on several antidepressants including mirtazipine. I found mirtazipine revolutionary for me on 2 occasions when I was acutely suicidal with depression, however it caused significant weight gain for me, on on occasion 3 stone in 3 months taking me from a size 10 to a 16. Weight gain and drowsiness are two of the main side effects, but they can be useful in people experiencing sleep or appetite problems.

A agree with everything Elarmarama has said, and she puts it much more succinctly than me. Part of the fascinating thing about mental health is that the same thing doesn't work for everyone and finding the right thing, or combination of things involves both the pharmacological skills but also all the soft skills, and the relationship you build with a patient is part of the treatment.

Ah welcome to another GP! I had a wry smile at your use of fascinating to describe the fact that the same thing doesn't work for everyone etc. I can think of other words to describe this conundrum!!!

Piratecat not everyone puts on weight with mirtazapine. I haven't and I'm on the highest dose. Mind I have changed my eating habits in case I do. On the leaflet in the box it says that 1 in 10 will experience weight gain, so a common side effect. I wondered if it was due to increased appetite or slow down of metabolic rate or both.

I haven't looked recently at the research on weight gain, there wasn't any available when I looked a few years ago. For me it made me crave carbs constantly. I was eating up to 5000 calories a day and had no self control whatsoever. As you say NanaNina, and in my experience some people don't gain any weight while others seem to put some on with or without being aware of an increase in appetite. Unfortunately like the effect on mood it affects different people in different ways. It does tend to be less sedating at higher doses for most people however.

Thanks for your insights, it's great to have another gp on the thread. wow!

I am very conscious of what i eat, so would hope to curb that, as i have totally changed my attitude to food the last 1 1/2 years. I know what works for me now.
I only put on weight gradually over about 6 yrs really, but have always been about a 12/14 naturally. I neatly hit and 18 in trousers so i just started Myfitnesspal jan 2012.

I am down to 20mg prozac the past two days and am going to see how that pans out before i see my gp in two weeks.

Amitryptaline? what do you think, a good thing for anxiety and sleep?

Good luck with things piratecat. Have a frank discussion with a GP you trust. Don't worry if they ask you what you'd like to do during the discussion about options, they're not expecting you to have a better knowledge than them, but they will want to make sure that you feel in control of things and are happy with the plan.

Amitryptaline can be good for sleep. It tends to be used in low doses these days for sleep/pain/low level anxiety and depression in the elderly. Much higher doses are needed to give a decent antidepressant effect, and it's infrequently used now just because newer medicines tend to have fewer side effects and are safer, however some people find it helpful.

Sorry can't comment on prozac but just wanted to say the way you describe feeling after taking the mirtazipine is how I felt when I first began taking it, thankfully the effects the morning after did lessen but I was always knackered to the point of slurring my words within half an hour of taking my tablet. For me it was a revelation to be getting a good nights sleep which is why I was prescribed it. Of course I can't say if it'll be the same for you but the morning after dizziness and general mind fog did fade after a while.

I didn't gain any weight on mirtazipine but was anxious about that. My wonderful old psychiatrist told me that it could increase my appetite but I was in control of that, IYSWIM?

I don't tend to prescribe amitriptyline for sleep though will sometimes still use it and other tricyclics in higher doses for depression. However, as NightFalls says, some people do find it helpful for sleep though I wouldn't think it would have much impact on anxiety at such low dose. However, a good nights sleep can work wonders of course.
I believe mirtazapine causes weight gain by increasing appetite primarily and it is probable that you'd notice some weight gain/appetite increase quite soon if it were going to be an issue with you. As others have mentioned, not everyone gets that side effect though.

Nana - dissociative disorders are where emotions/anxiety become overwhelming and in people susceptible to dissociation the mind copes by developing physical or psychological symptoms such as strong feelings of disconnection from reality, memory loss or other loss of function or sometimes symptoms that look a bit like psychotic symptoms. It's a surprisingly common problem but not perhaps talked about or diagnosed so much.

tiptops thankyou for all that info. x

Elamarama, that's very helpful about the amitryptiline. My gp gave it to me when i said i wasn't sure about having mirtazapine some months ago.

x

pirate, I've been on mirtazapine for about four months now, all the sedative effects do wear off. I haven't put on any weight, however, I'm trying to lose, and that is just impossible! Feeling better though.

hi there, my mum is on mirtazapine, she did put a bit on, say half a stone and is also finding it very hard to lose it.
how long was it until your dizzy effects stopped x

NightFallsFast, are you really a GP w/special interest? Just you misspelt both amitriptyline and mirtazapine. I am aware this post will make me appear a total spelling and grammar nazi........ but it seems like a GP would know the names of medications they have taken or are prescribing?

Oh my good god LongTimeLurking.

Nightfalls has taken the time to write out a very informative post and you are questioning her over a couple of spelling mistakes?

She might be on a crappy ipad. Or tiny phone. Or she might be dyslexic. Doctors are real people too.

Nasty, nasty, unnecessary post.

I was on both fluoxetine and mirtazapiene. I found that for the first 2 weeks or so on mirtazapiene I was quite groggy but it did wear off. It helped me to sleep really well, so did what I needed it to do. Now I'm just on fluoxetine again (60mg).

And the reason I came off mirtazapiene was weight gain - I had never had a problem with my weight before,but was just constantly starving!

Mirtazapine works differently from a lot of other anti-depressants in my experience. It was very helpful for sleep (literally knocks you out) and obliterated my depression without making me feel numb but also made me put on a lot of weight.

I don't think it is right to switch so suddenly from one anti-d to another but doctor (supposedly) knows best.

Wanted to add that the weight gain came straight off once I stopped taking Mirtazapine! It's a fantastic anti-d, the weight gain is it's only drawback.

catinboots, there was nothing nasty about my post. People can claim to be anything or anyone on the internet and I was simply saying to ME it seems a bit unusual that a GP would not know the correct spelling for common medications, especially one who claims to have a special interest in mental health.