Friday, May 18, 2007

Is THIS SSRI Withdrawal Syndrome???

Forgive the silly pic, I couldn't resist stealing it even if it doesn't quite fit.

This is a clinical case, but it's not my patient-- it's a little more personal than that, but still, no distinguishing characteristics, the names have been changed to protect my friends. You might ask why I'm rendering a clinical opinion on someone who is not my patient, who I haven't really examined but for pieces of a brief phone conversation, and that would be a good question. That can be it's own post, maybe one day when Roy is let out?

So I get a call from a dear friend from another state. Her father died last year shortly after being diagnosed with a terminal illness. Her mother happened to see her own GI doc and mentioned that her husband was dying. The story goes, "He told me it would be a rough time for me and prescribed paxil, it helped a lot." I personally don't prescribe medications simply for Hard Times or uncomplicated grief, and I didn't ask for a retroactive history, symptom list or mental status exam. She took paxil, it helped, time passed, she was doing better. So my friend's mother...let's call her Sally... spoke with her primary care doc who had her taper down off paxil cr 12.5 mg by taking one every other day then stopping.

The day after stopping she began to feel sick. Roughly 4-5 days later she was brought to the emergency room: she felt awful. Sally had a bad cold. She had a bad headache. She was confused, she began hallucinating. "Hallucinating? --She saw people moving, she woke someone in the middle of the night asking what a non-existent noise was, she insisted something wasn't written on a paper that was, repeatedly, until it was pointed at for her. Everyone was worried. I should mention that Sally is in her 80's, but she lives alone, drives, takes part in a number of organizations, and is the proud user of some of my favorite hair chemicals. She's not usually confused and she looks years younger than she is. She also suffers from a chronic GI problem, I don't know the rest of the medical history other than Hypertension and that med had been changed recently, too. And I don't know about past psychiatric history, but there's no psychiatrist in the story.

In the ER many tests were run, a brain CT was done. Nothing. The psychiatrist came and proclaimed "Paxil withdrawal." Relatives looked it up on the internet, all these symptoms have been described. She went home to wait it out, but she was feeling worse and worse and now developed a cough. Her primary care doctor said she could go back on Paxil but would then need to remain on it for life, and she didn't want to do this. Friend read on the internet that she could take a single dose of Prozac, which has a longer half-life than paxil, leaves the body more slowly, also increases serotonin levels, and this would help. Primary care doc agreed to call in a few prozac pills.

What did I think? Would this prozac thing work? He only called in 10 mg, was that enough?
Given that I didn't see the patient, I thought a lot, and I'll tell you my thoughts, as I told them.

1) This could be paxil withdrawal, though I personally have never seen anyone hallucinate and the hallucinations sounded a bit too close to delirium for me (Sally sounded fine on the phone). I was much more worried that something else was wrong, that an infectious process might be missed, that this could be related to her GI disease. This was my number one concern, though I was repeatedly told the ER did lots, all tests were fine, that 3 doctors had confirmed this was Paxil withdrawal.

2) Okay, so take a dose of paxil-- if it's withdrawal the symptoms should go away, soon and dramatically. Sally didn't want to do this because then she'd have to stay on paxil forever. No no no no no, I said, it would just be helpful to be sure that's what it was. She could take one dose, be sure she was okay, than happily withdraw. Or she could taper more slowly using 10mg and then 5 mg dosages.

3) Sally took the Paxil. She didn't know if she felt better-- not a good sign. The next day she took it again, she still had URI symptoms, now she had a low-grade temp. Confusion occasionally. The headache was better.

4) Friend wanted to give Sally the dose of Prozac. I said not to-- her symptoms had not resolved, I didn't think this was paxil withdrawal, adding Prozac would not help and she would be subjected to any side effects or adverse effects of the new medication.

The days went by, Sally did better, but hasn't returned to baseline. She's stayed on Paxil. She's staying alone most nights, still gets confused, and honestly, I haven't had an update in days.

The answer? I don't really know. I doubt that it was SSRI withdrawal given that some of the symptoms were not the usual and that she didn't get noticeably better after taking the Paxil. Though I do imagine this could explain part of the picture. Bronchitis (or pneumonia-- I don't know if a CXR was done)? Exacerbation of GI illness wouldn't explain headache, cold symptoms, but might explain some GI symptoms that developed after the Paxil challenge, the low grade fever, the likely delirium. Hopefully they're all doing better.
And just in case you thought I forgot my Novel obsession, here what people are saying about Double Billing over on The Interactive Novel Project:
Parked : "Now, you have my attention! Kudos! The first chapter just didn't hit me like the second one did. "
ClinkShrink: Wow, is that an improvement over the first chapter! The first chapter was just too short and sketchy and I felt no pull for the character. This is totally different. Very cool.
emy I. nosti: Love it. I'm hooked.


Roy said...

I like the yellow (rather than red) text better... doesn't hurt my brain.

One thing you didn't mention is drug interaction. Paxil inhibits the CYP2D6 P450 enzyme. This could have increased the level of another drug. Stopping the Paxil reverses the inhibition, causing a reduction in the level of the other drug, potentially causing withdrawal from THAT drug. Still, unlikely, as the inhibition would likely wear off more slowly than in your scenario.

Interestingly, I did see a case of serotonin withdrawal today. Person had been on Prozac 80 several months ago, but was stopped due to side effects. I'm asked to see pt due to agitation. Pt also had tremors, myoclonus, sweating, hyperreflexia, and increased muscle tone. That is 6 out of 7 of the Hunter criteria for serotonin syndrome (the doc had restarted the Prozac 80 mg on admission to the hospital).

Not sure what your pt had, but headache and brief periods (1-2 seconds) of lightheadedness are classic for SSRI withdrawal. The hallucinations are pretty atypical, and indeed suggest a delirium. Could be the GI drug, especially if it was an anticholinergic agent, like Bentyl or Levsin.

Anonymous said...

0 to 80 on prozac, wow! Not a fan of "start low go slow".

Okay, on my case, I don't know about other drugs and I specifically don't know about steroids, which could have been in the picture but weren't mentioned, and I figured the ER doc would have caught that in an 80something with a chronic GI disorder.
Lightheadedness wasn't mentioned, nor dizziness, and I asked about disequilibrium (no). Wouldn't you expect the symptoms to resolve with the resumption of the paxil? Low grade fever the next day... and would a drug interaction cause cough and uri sx?
Hopefully she'll just get better. I suspect a mix of etiologies here.

ClinkShrink said...

Has anybody checked an ammonia level? I've seen a low grade delirium where the LFT's were normal but the ammonia level was high, secondary to valproic acid. They stopped the VPA, the ammonia dropped and the sensorium cleared.

Anonymous said...

Given the age of the patient this does become most likely drug withdrawal. 12.5mg tapering was done too quickly for this woman. One thing I like to remember, as a Psychiatrist told me once, is tapering down from 20mg to 10mg to 5mg still leaves some drug interaction in your system. Do it slowly and write down all side effects. This is workable, but we have to remember that even 5mg to 0mg is where the real side effects come in. Now, there is no stored medication in the body. I believe she was taken off too quickly. Then you add inherently geriatric problems and everyone is second guessing.

Driving Miss Delusional said...

Why, I don't think I've ever seen you make a typo before.

Anonymous said...

Phelps talks about prozac bridging for Effexor discontinuation at bipolarworld.

It's a vital bookmark.

I run a site for mental health care consumers and have heard of nortryptiline being used in a similar manner.

I know damn well that's how I'm coming off Cymbalta when that day comes.

Sarebear said...

I didn't have hallucinations (I don't think) when I stopped Effexor cold turkey, but then, my eyes were closed most of the time for the first couple of weeks straight. I was a lump sprawled on the couch, no movement (as any little thing was bad) during the day, a lump in bed at night.

Gee, that sounds attractive, lol.

Okay, a very ILL lump? No, that sounds worse . . . . but I certainly didn't feel human, it was horrid. Anyway. I hope this pt is okee!

When talking about amphetamines today the iatrist mentioned maybe being sleepy and a bit off for a few days if I stopped taking, and I said, is it anything like when I stopped Effexor? He said NOOoooooooo. So that's good, anyway.

Is mixing etiologies anything like mixing metaphors, drinks, or company? hee hee. No, I know what it is, just being a dingbat (I didn't know I was a little image in a font file!)

altostrata said...

This poor woman might very well have had prolonged withdrawal syndrome, exacerbated by overdrugging with additional Paxil.

Antidepressant withdrawal syndrome is a very serious and probably common problem, about which medicine is in denial. Given the millions on these drugs, it probably affects thousands if not hundreds of thousands of people.

I am in my 5th year of recovery from Paxil withdrawal syndrome. I have had 18 months of disability. I am by no means the only person to suffer protracted withdrawal syndrome. For a collection of case histories, see There are hundreds of heartbreaking stories on the rest of the site.

Reading these patient reports may help the "shrinks" visiting this site educate themselves about withdrawal symptoms.

Currently, withdrawal syndrome, for which the psychiatric profession is entirely responsible, is an untreatable iatrogenic condition that destroys lives.

Until psychiatry recognizes the adverse effects of these medications, takes responsibility, and treats severe and prolonged withdrawal syndrome, its credibility is questionable. (And I haven't even mentioned promoting addiction to benzos.)

Are you practicing to help people or just to rake in the $$$ from cursory exams and refilling prescriptions?

Do feel comfortable deluding yourself about the safety of these drugs?