How it´s going – Completion of phase three

Hello Everyone!

I am now taking half of my original dose on both medications. So now I am on 75mg of Sertraline and 150mg of Quetiapine. There have been no unfavorable reactions to the dose reduction whatsoever. Again, I have to stress that I do not simply switch to a smaller amount of any of my medications from one day to the next. Every decrease in dose takes me about three weeks to complete. Also, I never modify the dose of both medications simultaneously, but do it one after another. This adds up to a total of six weeks for the change to be complete. I always start with the antidepressant, and finish with the anti-psychotic.

Given that I am feeling so well, I have decided to continue dose reduction throughout the month of December. I will take the Sertraline down to 50mg. In January, I will be travelling abroad, which is why I intend to wait with the further reduction of the Quetiapine dose until after the trip. I should point out that we will be visiting my partner´s family, and that I have made this same trip twice before. In other words: we will not be exposed to exotic stimuli and strange locations, but rather be welcomed into some sort of home from home. I find this important to mention because dose reductions are safest when there is no stressful situations or emotional turmoil ahead. Of course, these can come up unexpectedly at any moment and even in the middle of a dose reduction, but why deliberately risk any instability in the face of anticipated psychological pressure?

Once I am down to 50mg of Sertraline and 100mg of Quetiapine, which corresponds to one third of the original dose, I will not make any further changes for at least half a year. Frankly, I have not even clarified for myself if I should ever be completely medication free. The habit of popping those pills every morning and evening has become so strong and reassuring that the idea of not having them as a safety-net gives me vertigo. Knowing myself, I might be able to overcome that fear once I am getting closer to the right moment, but I am more of the one-step-at-the-time type, so for now I will be dealing with the next dose reduction and nothing beyond that. This tactic has worked fine for me until now, and not just regarding my medications but also other matters in life, so I shall stick to it.

I will keep you updated.

Felicia.

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Some Words on: Drug Interactions

Being on psychiatric medication will force you to question some of your habits. It might also make you wary about other drugs that had seemed harmless to you so far. Little things you took for granted may suddenly become big no-nos. I am talking about interactions your medication may have with other substances. For example, if you are taking a tricyclic antidepressant, popping an Aspirin against your headache is out of the question. You may have to renounce to alcoholic beverages and quit smoking bong. Possibly, you can’t even have caffeinated drinks.

Before you consider suicide, I wish to stress that despite the many restrictions your medication imposes on you, you will still find ways of enjoying life. I am just saying you need to be careful. The first step you need to take is to find out about the interactions your medicines may have with other prescription and over the counter drugs. Personally, I am on Quetiapine (Seroquel) and Sertraline (Zoloft). As a result, when I have pain from flu, from a migraine or caused by some lesion, I pretty much have to rely on Acetaminophen to fix it. It is the only analgesic and anti-inflammatory I can use without putting myself at risk. Every time I am about to try a new medicine I have to check and double-check if it is really safe for me to take. I admit to feeling quite nervous whenever I experiment with a new drug, although it is reported not to interact with my psychiatric medication. However, sometimes there is no way around playing guinea pig. Once I have successfully tried out a new drug I usually stick to it like glue. My list of compatible drugs is still short. Luckily, I don’t get ill often. Yet, eventually I should definitely make a list of all the medications I have found work fine for me.

It can be frustrating to find an entire group of medications is counter indicated for you, especially when you’re having an acute and debilitating health problem. You may have read in my withdrawal diary that I had been suffering from back pain. Unfortunately, I had to stick it out because there seemed to be no compatible muscle-relaxants. Usually, though, in every medication family, there should be at least one variety you can use. For example, there are several antibiotics which would interact with my psychiatric medication, but some are alright for me. The same goes for anti-allergic drugs. A couple of them would be dangerous for me to use, but Fexofenadine (Allegra) is harmless.

Not just other drugs can interact with your medication. Natural substances and food products can, too. All beverages containing caffeine are stimulants, meaning that, if your psychiatric treatment is aimed at calming you down, you will have to cut those out at least for a while. It is no coincidence that mental clinics usually offer their patients decaffeinated coffee and tea throughout the day. This may sound off-putting to the coffee-gourmets among you, but the nice thing about non-stimulating coffee is that you can literally have it around the clock and as much of it as you like. Personally, I love having several cups of coffee and tea per day. Yet, in order not to let it disturb my sleep, I stop consuming caffeine before 5 pm. Alcohol, on the other hand, is a potent depressant. So, if you are already down, having a few shots at your neighborhood bar will dig your grave a bit deeper. Doctors will generally recommend you to abstain from alcohol while taking psychiatric medications, or to enjoy moderate quantities on rare occasions. Your medications are broken down by the liver, so anything that would affect its functioning or strain it unnecessarily should be avoided. Now, alcohol is often a staple at social events. For many, having a glass of wine, a beer or a cocktail is part of the fun of hanging out with friends or colleagues. Probably, you can drink a glass or two without risking any negative effects. As for myself, I can have a few drinks without difficulty. I have never been a heavy drinker, not even a regular one. When I am at a party or at a restaurant, I like my share of red wine or a round of sake at sushi places. I never have booze on an empty stomach and also never let myself get drunk. If you decide you’d like to try a drink, accompany it with a glass of water to dilute and help you flush it out. An exotic item on the list of forbidden foods is the grapefruit. It alters liver function and therefore should not be consumed in combination with any drug at all – psychiatric or not.

Then, there are psychoactive natural remedies, such as Saint John’s Worth or Valerian. Extracts made from those plants are tranquilizing. In other words, they act on your brain. Only use them if you can make sure they won’t interfere with the therapeutic purpose of your current treatment. For the ladies, it might be an interesting fact that Saint John’s Worth, on top of its psycho-activity, also diminishes the effectiveness of hormonal contraceptives. So, hands off this shrub if you would like to enjoy your freedom for a bit longer!

Talking of natural psychotropic substances, there is a host of them. Probably the most commonly used is marijuana. Although it is illegal in most places, it is probably less dangerous than many psychiatric drugs. Still, it should not be used in combination with them. I am acquainted with people who are on anti-psychotics and smoke weed at the same time, but it is risky and therefore not recommendable. It can go well, or it can go wrong, without there being any way of telling beforehand. Unfortunately, little data is to be found about the risk factor here. It appears to be that recreational drugs can actually trigger mental illnesses. During my last stay at a mental clinic, I came across fellow patients whose diagnosis of schizophrenia or psychosis followed the use of marijuana, heroin or other illegal substances. Spontaneously, I can recall four or five cases, just out of the people I got in closer contact with. There is no way for me of knowing whether the physicians at the clinic recognized the cause of mental illness correctly, or whether factors other than recreational drugs were in play. Still, it is a possibility.

Sometimes, an illness or injury can require extra medication with great urgency. If it so happens, you will have to grind your teeth and weigh possible interaction symptoms against the gravity of your condition, then choose the least compromising of the two. Note that not all drug interactions are necessarily dangerous. Depending on their severity, they are usually categorized as major and minor interactions. Hence, if you are seriously ill, you may be willing to risk interactions as long as they are not menacing to your life. Just as side effects, interactions may occur in some individuals and in others not. If an undesired symptom is expressed in a very small percentage of the sample population, the odds are on your side.

Most importantly, you need to find reliable information on the interactions your medication may have. The package inserts (or PILs – Package Information Leaflets), usually only contain a basic paragraph on the subject. You can, of course, ask your prescriber, but he or she will likely not be familiar enough with the specific combination of drugs you are going to take. Remember your doctor sees dozens of patients every day, all of them with their specific medication plan. It is virtually impossible to bear all possible drug interactions in mind. Then, there is the internet. Several sites offer interaction finders where you can type in the combination of drugs you wish to check for safety. It is hard to say whether these webpages have complete data at their disposition. New medications are thrown onto the market and new studies with already existing medications are conducted all the time, so there is a constant need for updates. The advantage of online interaction finders is that you can type in any number of substances, which allows you to learn about the safety of multiple drug use. You can also find interaction lists on the internet. But be warned: the number of interactions for your psychiatric drug can literally be in the hundreds, so prepare for a Sisyphean task.

Last, but not least, your using psychiatric medication may be socially and professionally compromising. Not because you may have to turn down friendly offers of alcoholic or stimulating beverages, but because your medication may render you unresponsive to everyday situations. One day, instead of taking my antidepressant in the morning, I accidentally took the anti-psychotic. What a knockout! That day, I had visits coming over. Later in the afternoon I was supposed to shop for a birthday present and attend a theater rehearsal. I am hard headed as a ram, so I forced myself to pull through with my agenda, but it felt like attempting to pull myself out of a swamp. I won’t forget that day so easily. Normally, I am supposed to use my anti-psychotic right before going to bed at night. Now, there are some evenings where you have no intention of going to bed any time before the early morning hours of the following day. New Year’s Eve is one of those occasions. As a consequence, you may end up flushing your sedating medication down with a fruit punch at 2 am or so. As long as you have nothing important to do the next day, it’s not a problem. Just make sure you have no job interviews, driving lessons or college admission tests coming up, because you will be feeling quite heavy. Luckily, I am not much of a night owl, so the anti-psychotic does not really get in my way much. If you are into clubbing or have to work graveyard shifts, you will need to make adjustments either to your activity schedule or to your medication plan. Discuss this in depth with your prescribing physician. You may have to modify your lifestyle in some regards, but do not feel discouraged. If an aspect of your life is really important to you, there should be ways to conserve it. Stay motivated and think outside of the box.

The (Scary) First Step – Test Dose Reduction

The time has come! From tomorrow onwards, I will be taking a slightly reduced dose of my SSRI antidepressant. I will go from 150mg of Sertraline in the morning to 137,5mg for a week or two. This corresponds to a reduction of slightly less than 9%. Various sources recommend not to start with dose changes any greater than 10%. Therefore, although my next short term goal is to reduce my dose of Sertraline to 125mg, I will be going there through an intermediate step that will function as a test period at the same time. Both I and those closest to me will be monitoring my response – or the absence thereof – to this initial dose modification.

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My new toy – a “deluxe” (of course, I’m posh) pill cutter.

Now, how do I go about the dose reduction technically? I have 100mg and 50mg Sertraline tablets. They are of an oblong shape and dented in their middle in order to make halving them easier. But if I wish to try 137,5mg for a while, I will need to quarter the 50mg tablets. Even with my pill-cutter, that will hardly be possible. Reading through Dr. Peter Breggin’s book Psychiatric Drug Withdrawal (see sources), I found an easy enough solution to this problem. Breggin describes several drug withdrawals he was helping his patients with, and especially with very small dose modifications it was sometimes necessary to be inventive. This is what I’ve learned:

 

  • If a pill cutter won’t do the job, you can find out if your medications are available in liquid form as well. If they are, you can control your doses drop by drop.
  • Some drugs come in capsules filled with tiny pellets. Same as with drops, this gives you the possibility to make very gradual changes by removing some of the pellets from the capsule.

But careful: your mathematics must be very precise for both the drop-by-drop method and the pellet removal strategy. You need to figure out how much of the active ingredient is in a drop or in a pellet. If you are taking generics, you also need to make sure you are always using the same manufacturer, as concentrations and excipients may vary from brand to brand. And needless to mention, if you have trouble concentrating due to cognitive impairment caused by either your condition or your medication, you need to put an extra effort in getting your doses right. In the latter case, you may keep lists or put up sticky notes to remind you of how to proceed. If you live with someone who is willing to support you, you can also ask them to double check if you are handling your medication correctly and according to plan.

  • Given that I haven’t got hold of either Sertraline drops or capsules, I decided on another dose reduction method mentioned by Dr. Peter Breggin. I will be taking 125mg instead of 150mg every other day, simply by halving the 50mg Sertraline pill with the pill cutter and taking it together with the 100mg pill. Over time, the alternating doses of 125mg and 150mg will result in an overall dose reduction of 12,5mg.

If I tolerate this initial step well, I will proceed to definitely reducing my Sertraline dose to 125 mg. I am quite optimistic it will work because of experiences I have had with involuntary – alright, neglectful – dose reductions. For varying reasons, I have skipped taking my Sertraline altogether a number of times. Normally, I am rather disciplined and take the antidepressant immediately after getting out of bed and brushing my teeth in the morning. However, if a day is particularly eventful or something unexpected gets in between my waking up and my going to the bathroom, I run a slight risk of forgetting my Sertraline. The first few times it happened to me, I was extremely worried the omission was going to cause weird withdrawal symptoms or render me useless temporarily, but none of it was the case. My suspicion is that having used the same amount of Sertraline for about four years now, there might already be a certain concentration in my blood that keeps me stable even if I forget one pill every once in a while. This is just my personal hypothesis. Right now, I can name no sources to back it up scientifically. Also, so far I have never skipped more than one dose. Hence I don’t know how I would react to a permanent, if small, dose reduction. Still, for the above reasons, I am confident it should be no problem.

I will keep you updated on how things are going in my “withdrawal diary” section.

Why Wean off Psychiatric Medication?

If everything is going so well, you might wonder, why am I intending to give up my tablets? For several reasons! A variety of sources claim that using psychiatric medication over long periods of time can have dangerous consequences. Quetiapine, for example, is associated with altered blood sugar levels and diabetes. Damage to the liver is another risk. Tardive dyskinesia and tardive dementia (involuntary movements and dementia occurring after long-term use of psychiatric drugs) are other potentially irreversible side effects. Cognitive impairment and chronic brain impairment (CBI) are not uncommon. The long-term effects of psychotropic substances on the brain are virtually unknown, but they are suspected to be devastating. Apart from that, case studies indicate psychiatric medication can induce manic states and drive people to commit suicide or other violent acts. The very companies who designed the drugs I am using admit they don’t know how exactly their products act within the human organism. Looking at the monetary aspect of taking antipsychotics and antidepressants, it can get very costly! Either insurance rates are insanely high if you declare needing treatment for a chronic psychiatric condition, or you have to pay for your medication out of your own pocket. We are potentially talking expenses of several hundred dollars every single month. Many of you may also find that having to swallow tablets at certain times during the day is tedious and violates your liberty. I, on the contrary, find no reason to complain about that. Being a woman, I have used contraceptive pills for many years, and those need to be taken at the exact same time every day. You can never forget one, even if you are still spaced out from last night’s party – now THAT sucks! In other words, I find things could be much worse. I simply take my antidepressant at whatever time I choose to get up and the antipsychotic at whatever time I decide to go to sleep. I have even forgotten to take the antidepressant a few times – no problem at all, I simply make sure to take it the next day.

This blog is no manifesto against psychiatric medication. Psychotropic substances put the fire out in my case. They brought the acute crisis to a halt and gave me time to pick up the pieces. I am fortunate my organism accepted the current combination of an antipsychotic and an antidepressant well. Yet, I emphasize it is absolutely vital for recovery to find complementary, non-chemical therapeutic measures to extinguish the embers after the big fire is out. Because they might alter your brain forever, I consider psychotropic drugs the very last resource to be employed. In my eyes, they are an emergency switch that should only be thrown when a temporary shutdown of the system is necessary.

While in some cases medication may be useful, most people with prescriptions from their psychiatrist would be better off facing their crisis and managing it with their psyche unaltered. Soliciting the attention of a psychotherapist, counselor or priest, spending time with loving friends or family, regular workouts, healthy nutrition and decluttering an overloaded agenda often prove more healing than pills. It is important to remember that stress is a natural and even necessary condition. All human beings eventually experience crises. They will occur repeatedly in everyone’s life, so it is important we learn to deal with them. Rough patches are part of the natural course of our biographies, same as joyful times are. Instead of suppressing emotional tension chemically, we’d do better learning to get over it and thereby grow stronger. Only when all measures fail and the individual sinks into utter dysfunction and alienation, as I did, should medication be prescribed – temporarily. This is my personal and subjective opinion. I make no claim of being in the right.

Not all psychiatrists would agree with me, yet even within the discipline there is no consensus on when to administer psychotropic drugs to patients, nor on how many, nor for how long. Scientifically unfounded affirmations such as “psychiatric medication has to be taken for life” or “mental illness is incurable” are spooking around under the guise of objective information. However, the entire concept of mental illness is still hypothetical in many aspects. Preoccupied about my future, one day I phoned the psychiatrist who had treated me during my last hospitalization. I asked him whether I needed to take my medication for the rest of my life. He did not hesitate one moment. Much to my relief and surprise, his answer was “No.” He said I could start weaning off by lowering the dose of the antidepressant a bit, and take it from there step by step. The conversation with the doctor happened a while ago. I wasn’t ready then. Today I feel secure enough to have a go at it. I am aware one should never go “cold turkey”, that is, stop taking the medication from one day to the next. After over three years of using those substances, my brain relies on them to be around. Also, reactions to spontaneous or rushed withdrawal have been reported to be just as dangerous and terrifying as some of the unwanted side-effects of psychotropic drugs. I shall write more on the perils of withdrawal in another post.

Withdrawing from psychiatric drugs being such a delicate undertaking, I must remind you again: do NOT use this blog as a manual on how to proceed in your case. If you wish to benefit from my posts, read them attentively, share them with others, or even let my blog inspire you to put together your own action plan. So, if I may use an already overused line: don’t try this at home! Unless, that is, you have researched carefully and designed a strategy for modifications in your treatment that is tailored to your specific needs. I will later describe in detail about how I am planning my withdrawal process and which sources I am using for information.

My Medication History – Why I Was Prescribed Psychiatric Drugs

Four years ago, I suffered what is generally called a psychotic break – a severe mental and emotional crisis that pushed me into total dysfunction in everyday life. In retrospect I believe the event had been announcing itself over time. In the back of my mind I had had a notion that something was wrong with me for a good while. I had not resolved various conflicts generated during my childhood and young adult life. I now believe they had kept accumulating and necessarily had to lead to a paralyzing overload someday. When the big crash finally occurred, it felt very much as if a knot that had been pulled tighter and tighter over the years had ruptured and left my existence in shambles. One could very well speak of a major seismic event in my head and heart. I could feel my mind racing, yet completely unhinged and in idle speed. Emotionally, it was such a traumatic experience that I found myself in a constant and paradoxical state of combined panic and numbness. I was convinced I was irreparably broken. 

My symptoms apparently were not easy to classify. I literally received as many different diagnoses as I saw psychiatrists: major depression, bipolar disorder, schizoaffective disorder, schizophrenia. It is true that some symptoms of mental illness are common to all of these. There are no clear divisions between one mental illness and another, and psychiatry knows no scientific test methods to determine what you are suffering from. It is up to the psychiatrist to interpret what he believes to see in you. Also, most of the doctors I visited did not dedicate more than 10 or 15 minutes to our sessions, which is evidently not enough to make qualified observations, let alone guide me out of the crisis. In fact, the doctor who helped me most and invested the biggest effort in his patients’ well-being was also the one who saw no point in sticking a label on my problem. What mattered was my recovery. Further on, I will talk in more detail about my experiences with the psychiatric discipline – both positive and negative.

Before I was prescribed medication and the psychosis was in full swing, symptoms included: racing thoughts, sleeplessness, unorganized and contradictory thinking, unstructured speaking, inability to concentrate, incapacity of taking even the smallest decisions, paranoia, restlessness (akathisia), rigid stare, exaggerated need to make contact with people in the hopes of finding support, feeling existentially uprooted. At one point, I collapsed with what I now suspect to have been a minor stroke. I could literally feel an electric explosion initiating somewhere inside my brain and engulfing all of it in a few seconds. I began feeling ice cold and fell to the ground. I almost passed out. Terrified, I forced myself to open my eyes and get up. During the following hours, my legs would fold up under me, I had to force my eyelids open because they were constantly falling shut, and my speech was out of control – I was unable to form a thought and express it. My sentences were mostly incomplete. I also had no control over which of the languages I speak came out of my mouth. Despite my insisting to the people around me that something had “happened to my brain”, they preferred to believe I was just “low on sugar”. Even the psychiatrist who saw me a few days later did not consider it necessary to examine my brain. I felt I was in the wrong hands, but was powerless and exposed to other’s decisions. I described the incident to other doctors, but none thought it worth investigating. The first time I got a brain scan was seven months later. Around that time, also my blood and my thyroid were finally checked for anomalies. Nothing was found.

The first drug I was put on was the atypical antipsychotic Zyprexa (the active ingredient is Olanzapine). It did make me sleep, which no doubt was important. Yet, overall it had numerous unfavorable side-effects which added to the psychotic features mentioned above.  The negative effects were rapid and noticeable weight gain (about 35 pounds in six months), loss of willpower, deactivation of the menstrual cycle, lack of libido, unhealthy skin, and I still had that disturbing stare and was overall unable to engage in life.

When I got hospitalized for the third and – hopefully – last time, my medication was changed to 300mg of Seroquel (an atypical antipsychotic substance called Quetiapine) and 150mg of Zoloft (the SSRI antidepressant Sertraline). This cocktail seemed to work significantly better for me, and it is what I am still taking. All psychotic symptoms have vanished. The only downside is that I haven’t been able to return to my original weight – I am still about 25 to 30 pounds heavier than I used to be before the psychotic break. I also have recurrent nightmares and all sorts of unsettling dreams, which is a known side effect of Quetiapine. Apart from that, I am leading a happy and healthy life. I have a job, a partner, friends, pets, hobbies and a good overall health. My cognitive capacities are as good as they have ever been – I am pursuing a Master’s degree and also enjoy acquiring new knowledge and skills in my free time. Nothing is missing. Luckily, I have not noticed any cognitive disabilities caused by the medication. Although everything has been going just fine, my lifestyle needed to undergo major changes. Today, I am more careful with myself than before the crisis. I have become more conscious and protective of my mental and emotional health. I didn’t really know how precious it was until I lost it! Before the psychotic break, I tended to be merciless with myself. My schedule used to be crammed with duties and I seldom allowed myself to rest. In fact, relaxing would make me feel guilty and useless. In those days, I was notorious for my iron discipline and efficiency. I was working non-stop to keep up with my obligations. Today, I am way less masochistic. In fact, I’ve begun liking and trusting myself. I now consider spare time an important and pleasurable part of my schedule. I am still a busy person, but I am more selective as to which chores I fit into my day and to which ones to say “no”. Even when things get a bit intense at times, I don’t allow stress to take over. Of all the tasks that are at hand, I figure out which should be completed first, and I focus on that one. Then, I pick the next one, and so on. Tackling challenges one by one works a lot better than looking at the huge pile of responsibilities and getting overwhelmed by it. I also find I have become more discerning as far as priorities and not-so-important matters go. Allover, I’d say I am living more consciously and more lovingly towards myself and others. Definitely, life is more fun and more fulfilling now. It is something I believe everyone should strive for – mentally ill or not.

Personally, I am certain that medication alone did not put me on this new, better path. Many, if not the majority, of my fellow patients at the clinic were just as miserable on medication as they had been without it. I believe that love, attention and spiritual support from people close to you are at least as important as the correct prescription. Also, the last clinic I was in had a tight schedule of therapeutic activities which forced the patients to remain busy and engaged in reality. The staff was available for one on one support most of the time. In my view, it was the accumulation of all these factors plus my own striving for emotional wellbeing that helped me back into life. In fact, I now feel more secure and at peace with myself than I had ever felt before the psychotic break. Why that is so, I cannot be sure.  My becoming better may be, and that I would consider the worst case scenario, the sole merit of my medication plan. It is also possible, which I hope is the true cause, that the pills have, metaphorically, pushed my reset button and thereby allowed me to tackle my old conflicts and the challenges of life step by step, until seeing me out of the worst.