My Cymbalta Withdrawal - Review of the Trilogy

I've blogged about my ongoing withdrawal from the antidepressant Cymbalta since I started tapering doses on March 20. In that time I've written three posts sharing my experience with the most recent being "My Cymbalta Withdrawal - Return of the Mind."  

This post is a review and summary of the first segment on my journey to 0 mg/day so far. But with a twist. I am inserting characters and adding plot that represents the Star Wars series.  Why not, right?

The Trilogy

1.  Withdrawal Wars. In "Withdrawal Wars" we find our hero, Duke Taperwalker, at the very beginning of the discontinuation process when he went down from 120 mg per day to 100 mg per day. We come to find out through the master obi-one-clinician that he needs to clear himself of the toxic antidepressant before he can begin to clearly access the Life Force.

Duke had high hopes since he has made it off several psych meds without invoking the wrath of the Discontinuation Syndrome. He's thinking Cymbalta withdrawal will go smooth and last less than six weeks or two months max. Our protagonist is not aware of the evil biopsychoneuropharmacology that lurks in the not-so-distant future. 

2.  The Syndrome Strikes Back. In "The Syndrome Strikes Back" post we find Duke eating a little humble pie.  The withdrawal from Cymbalta took a turn for the worse. He has been overpowered by the Dark Side and is experiencing severe symptoms from the evil warlord Darth Depression.   

It started at the beginning of the second week when they dropped Duke's dose to 80 mg per day. The psychmed rebel fighter began experiencing severe depression, which became mild by the end of the week. During the third week the depression became severe again, but this time worse than the prior week! And the fourth week was like the third. 

Even though young Taperwalker stayed at 80 mg per day, he continues to experience attacks from Darth Depression.  

So, we leave our hero devastated and trapped by the intensity of withdrawal symptoms. The Syndrome has regrouped and attacked with ferocity.  What now?  Where will this perilous journey lead him?
    
3. Return of the Mind. In "Return of the Mind" we find Duke pleasantly surprised and thoroughly relieved by the remission of Darth Depression. However, drug recon data and recent Cymbalta withdrawal symptoms indicate this is going to be a long and arduous process.

The episode starts at a point where the withdrawal from Cymbalta took another big turn. This time for the better! It is near the end of fifth week and he remains at 80 mg per day. Duke has actually had as much as six days in a row with only mild depression!!
It looks like the kid might be stabilized with intermittent, mild depression. He has remained in communication with his rebel leader psychiatrist, Dr. G, on a weekly basis throughout this withdrawal process. 

At the end of the fifth week the Executive Council of the Psychmed Rebel Alliance was convened to decide what to do next. Even though it was not clear what direction Duke's withdrawal symptoms were heading, the recommendation was to stay at 80 mg/day for a few more days and see what happens. It turns out that was a good move!

It is now the end of the fifth week of this episodic battle to get off Cymbalta. Duke Taperwalker has defeated the Discontinuation Syndrome once again!  His mind is clearer and his mood is significantly better. The psychmed rebels are enjoying an extended period of peace between the dark and light sides of the disordered universe. There is hope once again in the Pharma Galaxy!

What's Up Cymbalta What's Up?

I have had better moods lately because we paused the campaign to rid my body of Cymbalta. I've been at 80 mg per day for over five weeks now.

My psychiatrist wants me to stay at 80 mg for an unspecified period of time, but I'm wanting to press on, but respect for her recommendation resulted in a compromise. I agreed I would stay at 80 mg per day for four weeks and at that time evaluate my progress to determine whether to lower my Cymbalta dose or not.

My Cymbalta Withdrawal - Return of the Mind

This is my third post regarding the continuing saga of my withdrawal from the SSRI antidepressant Cymbalta.  It may be helpful to read my earlier posts on this topic: (1) Bipolar Treatment Update - Cymbalta Wars and (2) My Cymbalta Withdrawal - The Syndrome Strikes Back. 

Background

I have been on Cymbalta for six years.  It was added to augment Wellbutrin, my primary antidepressant, and improve treatment of lingering depression symptoms.

Although it worked for several years, I have come to believe that Cymbalta is no longer effective for me as an antidepressant.  It's known that antidepressants can be effective for a period of time (months or years) and then stop working.

Poop Out
  
A loss of effectiveness during antidepressant therapy can occur with most antidepressants.  A sustained, effective response from antidepressant treatment is not always achievable.  

Unfortunately, it's not fully understood what causes this so-called "poop-out" effect, or why it occurs in some people and not in others.  This effect could relate to the disease itself, pharmacological effects, or a combination of the two. 

Tapering - The Slow Withdrawal

I began tapering down from 120 mg/day of Cymbalta (a very high dose) on 3/20.  I dropped to 100 mg/day for the first week without significant problems.  

But when I went down to 80 mg/day at the start of my second week all hell broke loose.  It felt like a depression alien life form came and infiltrated my mind.  Since then I have had many days with mostly severe depression.  Not good.

Status

Well, my withdrawal from Cymbalta took another big turn lately. This time for the better! My depression has began to lift again. The intensity of my symptoms really dropped and since last Tuesday I've had mostly mild depression!! I remain in communication with my psychiatrist throughout this withdrawal process. We almost went back up to 100 mg/day at the beginning of last week because things were so bleak. On Monday we decided to stay at 80 mg/day for a few more days and see what happens.  It turns out that was a good move!
By the Way 

Adverse withdrawal effects and the discontinuation syndrome from Cymbalta are real.  They can be devastating to a certain percentage of users.  If I recall correctly this figure is in the 10 to 20 percent range.  Withdrawal effects are mostly overlooked by Pharma.  Because of this patients get taken by surprise when they try to get off the drug and experience a debilitating withdrawal process instead.

There are numerous papers, articles, and web sites that specifically address Cymbalta's under reported withdrawal effects.  Cymbalta Withdrawal Forums is a site I found helpful.  It used by folks dedicated to rooting out and addressing the adverse effects that can arise while getting off of Cymbalta.  Cymbalta Attorney gives you direct access to lawyers specializing in Cymbalta withdrawal and injury cases.  I'm sure they'd take my money, but I think I'll pass.  Cymbaltawithdrawal.net is another site that addresses Cymbalta withdrawal only.  It's not a good site but thought I'd include it for no specific purpose anyway.  

What's Next?

I will discuss my situation via email with my pdoc tomorrow.  Since things have lifted for several days in a row now she may okay lowering my Cymbalta dose some.  

I'm leaning towards remaining at 80 mg/day for another week to be safe.  This stuff is dangerous!  Also, we need to figure out how what the next tapering dose will be.  

Another 20 mg/day reduction in dosage is an overall drop of 25 percent.  Hmmm.  Maybe a bit much?  

How much would you decrease the next dose?

My Cymbalta Withdrawal - The Syndrome Strikes Back

Man, this has been a really difficult post for me to write.  I have been going through severe withdrawal symptoms (a.k.a. discontinuation syndrome by the medical community) from Cymbalta.  

The depression symptoms I experience keep me from writing.  My mind is dull and slowed with significant cognitive impacts.  Concentration, working memory, and attention is really messed up.  

I'm getting the “impending doom” type of anxiety.  It comes and goes.  I struggle to fight the barrage of negative thoughts.  Those suckers make the depression seem permanent, like it will never subside.  Fatigue, hypersomnia, and anhedonia (lack of interest, motivation, pleasure from normally enjoyable activities) are pervasive when my depression symptoms are this strong. 

The Situation

I have mentioned before that I am in the process of getting off Cymbalta.  It is the second of my two antidepressants.  I have been on Cymbalta for around six years.  It was added to Wellbutrin, my primary antidepressant, to help relieve lingering depression symptoms.

Although it helped my bipolar depression for several years, Cymbalta is no longer effective for me as an antidepressant.  It's well known that antidepressants can be effective for a long period of time and then stop working.  Unfortunately, it's not fully understood what causes the so-called "poop-out" effect, or why it occurs in some people and not in others.

Withdrawal

I discussed going off of Cymbalta with my psychiatrist, Dr. G.  She agreed and planned for me to taper off 20 mg/day each week from 120 mg/day (starting point) to 60 mg/day.  We would evaluate things at 60 mg/day and proceed accordingly.   

1st week (3/20-3/26).  Lowered dose from 120 to 100 mg/day.  Not much change except a little nausea.  Depression was similar to the week prior.  Depression was mostly mild during the week with a couple of moderate depression states.  

2nd Week (3/27 – 4/2).  Dose lowered from 100 to 80 mg/day.  Mood started okay but depression became severe by the second day (3/28).  Depression is moderate to severe for about two and half days at the beginning and mostly moderate to mild for the rest of week.

3rd Week (4/2 – 4/8).  Stayed at 80 mg/day.  This week was worse than the prior week.  I was severely depressed for four days in a row.  Depression began lifting on Friday night (4/6).  Certain symptoms are becoming stronger, like sadness and worthlessness.  Yuck. 

Status

I’m near the end of my fourth week.  The dose remains at 80 mg/day.  Like the two weeks prior I continue to experience days of severe depression.  This time it was five straight days for most or all of the day.  Today is Sunday and it seems like it finally lifting again.  I’m going backwards!   

Now What?

I’m sure glad we stayed at 80 mg/day.  It’s very likely the withdrawal effects would be worse if I had continued to lower the dose.   

I will email my doctor Monday with an update.  I’m not sure what she will say.  She may want me to go back up to 100 mg/day.

I’m going to bring up the idea of taking Prozac to control these Cymbalta withdrawal symptoms.  I’ve read this online in forums and articles.

One article I read today reports that Benadryl (dipenhydramine) helps with withdrawal symtoms.  I just started taking that today.

Summing It Up

Well, withdrawal from Cymbalta is not going as I'd expected.  I thought it was going to be without problems since I tolerate antidepressants well overall and I successfully got off Abilify several months ago.

Now I’m not sure what’s going on.  I just keep moving along.  I feel like Frosty the snowman when I tell myself “I’ll be back again someday.”  I will keep you posted as this perilous journey to de-Cymbaltanize myself continues.

Meth and LSD for Bipolar Disorder!

April Fools!!  Really now!  Such a notion, meth and LSD for bipolar disorder.  Those things probably cause bipolar disorder.  I'm not sure on that.  They definitely mess up bipolar symptoms, according to my friend Anon.  I think I'm going to remove this post after today.  I know I would be upset if I searched online for "Meth" and "LSD" and "Bipolar" and landed on this page, ha ha.

Last Week

I had bad depression last week.  I didn't write much because of it.  It's Saturday today and this is my first time writing all week.  The post last Wednesday, "Bipolar Tip: Winning at Your Next Pdoc Visit!" was written the week prior.

I spent most of my "useable" time this week researching ketamine.  It's has potential for use treating bipolar depression.  It's a powerful drug with strong antidepressant effects that has seemingly stalled in its development.  Look for a post on ketamine later this month!

Cymbalta Withdrawal

As I posted a couple of weeks ago I am currently getting off Cymbalta.  This is still the case, but I think I'm getting some  withdrawal effects from it.  I have been markedly lower lately.

My tapering plan from my pdoc planned for lowering my dose by 20 mg/day a week at a time.  I went from 120 to 100 mg/day with seemingly no problem during week one.  Tuesday I lowered my dose to 80 mg/day.  That same day my depression symptoms (mood, fatigue, tiredness) fell from mostly moderate to mostly severe and its been the same since!

So, it seems like my withdrawal from Cymbalta is not going to be as simple as I'd hoped.  I'll call up my psychiatrist tomorrow and figure out what to do.  

Have a great week!

Bipolar Treatment Update - Withdrawal Wars

Changes are underway with my treatment plan.  I'm getting off of my antidepressant Cymbalta (duloxetine).  I've been on the drug for over 5 years now.  The reason for withdrawal is not for side effects, but for efficacy and safety concerns.


Cymbalta  

I've determined Cymbalta is no longer helping my bipolar depression.  And I recently discovered there are serious adverse effects from taking both Cymbalta and Wellbutrin (bupropion) at the same time, which I do.

I used an online drug interaction checker tool from Medscape.  It said "Serious - Use Alternative duloxetine + bupropion duloxetine increases toxicity of bupropion by unspecified interaction mechanism. Serious - Use Alternative. May lower seizure threshold; keep bupropion dose as low as possible.  Oh, my.


Psych Meds

• Cymbalta:  Remove.  Starting 3/20/12 I am tapering from 120 mg/day to 60 mg/day over three weeks (20 mg decrease each week).  Evaluate, then continue tapering until 0 mg/day.

• Lamictal:  300 mg/day.  No change.

• Wellbutrin: 450 mg/day.  No change.

• Xanax: 0.9 mg/day. Slight increase in use.

• Abilify: Completed withdrawal in December 2011.

Supplements

NAC: 2000 mg/day, started two months ago. Not sure of response really.  Will continue during Cymbalta withdrawal; fish oil - 300 mg/day; multivitamin; aspirin; and caffeine.


Additional Information

• Psychotherapy.  My therapy sessions are going well.  I go once a month.  This therapy gives me a clearer sense of what's really going on with me and I receive helpful feedback and insight.
• Withdrawal effects.  I am concerned about possible adverse effects from Cymbalta withdrawal.
• Supplement interactions.  Possible adverse health effects from supplements with psych meds.  I need to figure this out myself.

Conclusion

I am continuing to actively manage my medication treatment. I have some alternative/novel antidepressants I am interested in trying after Cymbalta withdrawal.  However, the pdoc is not so hot on it.  Something about side effects and hallucinations or something.

I am fortunate.  Because of high tolerance to psych meds I am able to use them and stop them with minimal adverse effects.  But who knows with Cymbalta?  This could be a protracted, agonizing period in my life like it is for an unfortunate percentage of those who suffer severe (sometimes debilitating) withdrawal symptoms.

I don't expect that, but then again this could be just the beginning of my fight against adverse withdrawal effects.  Could this be the start of "Withdrawal Wars?"

Medication Withdrawal Effects

I've been searching the web lately trying to better understand potential adverse health effects from psychiatric drug withdrawal.   Why can one person get off a psych med without hardly an ill effect while another will suffer for months during the process?  Hmmm, this looks interesting.

Each person's brain/body responds differently to drug withdrawal, just as each brain/body reacts differently to a new drug.  In the latter the process can produce adverse reactions we call side effects.  For drug withdrawal, troublesome symptoms are usually called withdrawal effects.  A more fancy term being used is discontinuation syndrome.

Withdrawal Effects.  Withdrawal from psychotropic medications can include flu-like symptoms such as fatigue, lethargy, aches, insomnia, diarrhea, nausea, and dizziness.  Some people become hospitalized because of the withdrawal process.  The experience can be horrible and last months or even years according to those who've been through a bad withdrawal.

In an online web forum one practicing M.D. was quite critical of the withdrawal effects from psych meds.  He lamented that there are some patients who's experiences are so bad that they end up deciding to stay on the drug, even when they have determined it has no therapeutic value for them.  They were stuck on a drug that wasn't working because withdrawal was too excruciating.  What's worse, some unfortunate souls in this situation continue to experience withdrawal effects even after getting back on the drug!

From an article on antidepressant withdrawal, the writer says withdrawal effects are more likely to occur (a) if you have been on the medication for six weeks or longer and (b) if you are within the first two weeks of the tapering off process.

Drug withdrawal symptoms are reported across the psychiatric spectrum.  An article in the journal Medical Hypothesis reports withdrawal effects in antidepressants, antipsychotics, lithium, and benzodiazepines such as Xanax.

I was quite concerned about withdrawal effects from the antipsychotic Abilify (aripiprazole) during my recent tapering off from it (see my last post on 12/12/11 about this).  I didn't do much research before stopping.  I just hoped for the best.  Fortunately things worked out well for me.

Some personal websites were particularly grave about the withdrawal effect.  I bet these folks are the unfortunate ones who have debilitating symtoms that can last for many years.

We certainly need more research in this area.  Without more information it is difficult to compare the risks and benefits of stopping.  Perhaps there are other medications or practices we can do to minimize the withdrawal effect?

One big step in the right direction comes from a new company adverseevents.com.  They are making it possible to readily find information about the toxic effects of medications including psych drugs.  Their process uses a propriety algorithm to extract data from the FDA's Adverse Events Reporting System (AERS) and assemble the information into a useable and understandable format for patients and healthcare professionals.

Paxil. One drug that kept coming up was the SSRI antidepressant Paxil (paroxetine).  According to a the Mayo Clinics Medical Edge Newspaper Column, Paxil is in a group of SSRIs that are the most difficult to quit.  This is because certain SSRIs are metabolized (removed from the body) more rapidly than other SSRIs.

In one blog post the author explains her experience with Paxil withdrawal effects.  Her reaction was so severe that they had to allow seven months for her to taper off.   Withdrawal effects included headaches, lethargy, depression, dizziness, the "zaps" (whatever those are) and nausea.  At the same time she says a close friend withdrew from Paxil with only headaches.

Adverseeffects.com reports withdrawal effect information about Paxil.  Data they have from consumers between 1/1/2004 to 6/30/2011 that shows withdrawal from Paxil has a hospitalization rate between 5 and 7 percent!  Wow, who knew?

I don't remember any withdrawal effects when I got off Paxil about 10 years ago.  Maybe I was too depressed to notice.  I remember I didn't respond well to the drug therapeutically.

Takeaway message.  The symptoms from tapering off vary a lot from person to person and drug to drug.  Trying to determine who will experience withdrawal effects and how severe those effects will be is really anybody's guess at this point.

We need to explore whether the long-term recommendation for bipolar disorder treatment should be indefinite use of psych meds?  Should medication for life really be the presumptive remedy?

Finally, when stopping a medication it is critical to work with your psychiatrist so that the tapering off period is as gradual as necessary to control the withdrawal effects.  You need to start low and go slow.