![[dr. bob]](/dr-bob-sm.gif)
Dr. Bob is Robert Hsiung, MD,
bob@dr-bob.orgShown: posts 2 to 26 of 26. Go back in thread:
Posted by ed_uk on December 3, 2004, at 7:47:07
In reply to EPS from SSRI or other Antidepressants?, posted by Mr.Scott on December 2, 2004, at 23:52:38
Hi! Here are some reports of EPS with SSRIs..............
Fluoxetine-induced akathisia: clinical and theoretical implications.
Lipinski JF Jr, Mallya G, Zimmerman P, Pope HG Jr.
Laboratory for Psychiatric Research, McLean Hospital, Belmont, Mass 02178.
Five patients receiving fluoxetine (Prozac) for the treatment of obsessive compulsive disorder or major depression developed akathisia. The typical fluoxetine-induced symptoms of restlessness, constant pacing, purposeless movements of the feet and legs, and marked anxiety were indistinguishable from those of neuroleptic-induced akathisia. Three patients who had experienced neuroleptic-induced akathisia in the past reported that the symptoms of fluoxetine-induced akathisia were identical, although somewhat milder. Akathisia appeared to be a common side effect of fluoxetine and generally responded well to treatment with the beta-adrenergic antagonist propranolol, dose reduction, or both. The authors suggest that fluoxetine-induced akathisia may be caused by serotonergically mediated inhibition of dopaminergic neurotransmission and that the pathophysiology of fluoxetine-induced akathisia and tricyclic antidepressant-induced "jitteriness" may be identical.
Acute dystonic reaction in an elderly patient with mood disorder after titration of paroxetine: possible mechanisms and implications for clinical care.
Arnone D, Hansen L, Kerr JS.
Department of Psychiatry, Old Manor Hospital, Salisbury, UK. Danilo.Arnone@wshsc.nhs.uk
The administration of a serotonin reuptake inhibitor may lead to extra pyramidal signs, as reported in the literature. The risk seems to be increased in elderly people. We describe a case of acute dystonic reaction to paroxetine (Paxil/Seroxat) treatment in an elderly patient, who presented with a bipolar affective disorder. The underlying mechanism, possibly generated in the subcortical motor areas, is linked to changes that occur in the pharmacokinetic variables, the decreased neuroplasticity of ageing neurones and to previous exposure to neuroleptic medications.
Sertraline induced parkinsonism. A case report and an in-vivo study of the effect of sertraline on dopamine metabolism.Di Rocco A, Brannan T, Prikhojan A, Yahr MD.
The Mount Sinai Medical Center, Department of Neurology, New York, NY, USA.
We report a patient with a parkinsonian syndrome induced by sertraline (Zoloft), an SSRI antidepressant, whose symptoms resolved after the drug was discontinued. This case prompted us to investigate the effect of sertraline on dopamine metabolism in animals. Sertraline (30 mg/kg, i.p.) or placebo (vehicle) was administered to two groups of six normal, anesthetized rats and using cerebral microdyalisis extracellular striatal levels of dopamine, the dopamine metabolites (HVA and DOPAC), as well as the serotonin metabolite 5-HIIA were monitored. In animals pre-treated with sertraline, DOPAC, HVA, and 5-HIAA levels were significantly decreased compared to control animals (p < 0.01). These data indicate that sertraline has an effect on dopamine metabolism, which may alter function in the striatum and induce a parkinsonian syndrome.
Tardive dyskinesia associated with fluoxetine.
Dubovsky SL, Thomas M.
Department of Psychiatry, University of Colorado School of Medicine in Denver, USA.
Three cases in which patients who were taking fluoxetine for relief of depression showed patterns of abnormal movements suggestive of tardive dyskinesia are presented. In the first case, abnormal facial movements began four weeks after fluoxetine was added to doxepin and lithium and remitted after fluoxetine was discontinued. In the second case, abnormal movements of the mouth and hands were noticed four years after the patient started taking fluoxetine and continued to be present a year after withdrawal of the medication. In the third case, orofacial dyskinesia that had remitted after withdrawal of sertraline and paroxetine and reappeared with fluoxetine was still present eight months after fluoxetine was withdrawn.
Posted by SLS on December 3, 2004, at 10:08:13
In reply to Re: EPS from SSRI or other Antidepressants?, posted by ed_uk on December 3, 2004, at 7:47:07
Hi.
Of the tricyclics, it is amoxapine that carries with it the greatest risk of EPS. I have never heard of EPS with the others. There certainly are reports of EPS with some of the SSRIs. I would be curious to know what the mechanisms are behind this. Perhaps there is a depletion of dopamine in the striatum.
- Scott
Posted by Ritch on December 3, 2004, at 13:36:11
In reply to EPS from SSRI or other Antidepressants?, posted by Mr.Scott on December 2, 2004, at 23:52:38
The only two symptoms that I clearly think are EPS which I get from SSRI's are lower back dystonia and tongue pressing up on the roof of my mouth. The lower back thing I only notice when I am sitting in a car seat and my lower back muscles involuntarily twist to one side and stay there. I notice it and force myself to sit still and relax them, but after a while I notice it again. It's similar to the dystonic muscle thing I got from Haldol once. The Haldol thing was far worse-I couldn't stand up at all for about 24 hrs. The tongue thing is very similar to what happened to me with Stelazine. OF course the Stelazine thing was far worse (I couldn't talk clearly), and I had a severe neck dystonia along with it.
Paxil was the worst SSRI in this regard (4mg liquid one time-and that was it for me!). Celexa tends to do the lower back thing worse than the others. Effexor seems to be the worst for neck rigidity. Cymbalta and Zoloft were the worst for akathisia and restless legs.
I think it suppresses dopamine just enough to uncover the symptoms. I've always been sensitive to EPS. The only two AP's I could take was low dose thioridazine and thorazine. Too bad I took the thioridazine for several years. I guess I'm just dopamine compromised and suppressing it in the slightest makes the symptoms show. As far as the mechanism that SSRI lowers DA goes.. I'd like to know too. I thought it was 5-HT receptor *agonism*, right? Maybe what is needed is a selective 5-HT receptor agonist (that doesn't target the ones causing mild EPS sx)??
Posted by ed_uk on December 3, 2004, at 13:46:38
In reply to Re: EPS from SSRI or other Antidepressants?, posted by Ritch on December 3, 2004, at 13:36:11
Hi!
Has anyone ever tried an anticholinergic such as orphenadrine (Disipal) to treat EPS caused by SSRIs? The reason I mentioned orphenadrine in particular is because it is also thought to be a mild analgesic and is occasionally prescribed to treat back pain. Anticholinergics are the most common treatment for AP-induced EPS. Other common anticholinergics include procyclidine, trihexyphenidyl (benzhexol), benz(a)tropine and biperiden.
Another way to treat SSRI-induced EPS might be to use a 5-HT2 antagonist such as mirtazapine (Remeron). Take care if you suffer from akathisia, high doses of Remeron may cause restlessness!
Regards,
Ed.
Posted by Mr.Scott on December 3, 2004, at 21:52:57
In reply to EPS from SSRI or other Antidepressants?, posted by Mr.Scott on December 2, 2004, at 23:52:38
Hi,
I've treated my EPS symptoms which range from increasing restlessness, muscle tension, dystonia in my leg and back, and myoclonic jerks throughout my entire body eventually leading to muscle pain, fatigue, and soreness in two ways. Dopamine enriching drugs such as amphetamine, although Watch Out on the crash for a rebound. And also I used benztropine. The benztropine caused so many anticholinergic side effects it made Elavil look like a godsend. I'll take my god given depression before benztropine any day!
Scott
Posted by Peddidle on December 3, 2004, at 23:44:50
In reply to EPS from SSRI or other Antidepressants?, posted by Mr.Scott on December 2, 2004, at 23:52:38
I began experiencing muscle twitches after I started weaning off my zoloft a couple of months ago. I got down to 50mg, then went up to 100mg (because I couldn't stand the withdrawal), and I've stopped for now. I thought the muscle twitches for more of a nuissance than anything else and that they would just go away after a while, but they're definitely still there, albeit not as bad.
Posted by ed_uk on December 4, 2004, at 17:55:46
In reply to Re: EPS from SSRI or other Antidepressants?, posted by Mr.Scott on December 3, 2004, at 21:52:57
Hi Mr. Scott,
Have you considered trying one of the dopaminergics that are used in Parkinson's disease? You could try a low dose of levodopa (L-dopa).
Regards,
Ed.
Posted by Mr.Scott on December 6, 2004, at 22:19:37
In reply to Re: EPS from SSRI... To Mr. Scott, posted by ed_uk on December 4, 2004, at 17:55:46
Hello and Thanks,
I'm going to be switching doctors in January when my insurance changes. The new one is a neurologist and a psychiatrist. I will mention those newer dopamine drugs for parkinson's. My current doctor is too scared to play with much of anything outside of what the drug reps drop off.
Just a side note here: I can't imagine what people did for chronic depression prior to modern medicine. I'd like to know since I seem to be one of those who still doesn't benefit. How'd they pull it off?
Scott
Posted by Peddidle on December 7, 2004, at 2:07:09
In reply to Re: EPS from SSRI... To Mr. Scott » ed_uk, posted by Mr.Scott on December 6, 2004, at 22:19:37
I actually took a History of Medicine class last semester...I'll see if I can find out and get back to you. :)
Posted by Mr.Scott on December 7, 2004, at 20:17:29
In reply to Re: EPS from SSRI... To Mr. Scott, posted by Peddidle on December 7, 2004, at 2:07:09
Posted by olysi79 on December 12, 2004, at 16:39:41
In reply to Re: EPS from SSRI or other Antidepressants?, posted by SLS on December 3, 2004, at 10:08:13
I beleive that I am possibly going thorugh some kind of mixed state or Akathisia right now from my SSRI... I have no idea on what to do because I need the SSRI...
Posted by Mr.Scott on December 13, 2004, at 21:34:41
In reply to Re: EPS from SSRI or other Antidepressants?, posted by olysi79 on December 12, 2004, at 16:39:41
Can you elaborate? What are your symptoms? Have you called your doctor yet? Don't let it go too long without contacting the doctor.Scott
Posted by yxibow on December 13, 2004, at 23:55:40
In reply to Re: EPS from SSRI or other Antidepressants?, posted by olysi79 on December 12, 2004, at 16:39:41
> I beleive that I am possibly going thorugh some kind of mixed state or Akathisia right now from my SSRI... I have no idea on what to do because I need the SSRI...
A very select few SSRIs can cause akathisia, I think, esp. in combination with other medications. Zoloft and Prozac I believe are the worst offenders although they are probably milder than AP akathisia. I would definately consult with your doctor. If its merely restlessness, a bit of propranolol does wonders and you probably can continue taking it for the time being and maybe think about discontinuing it for another SSRI or perhaps trying the recently released SSNRI Duloxetine/Cymbalta.
Greets
Posted by ed_uk on December 14, 2004, at 8:02:23
In reply to Re: EPS from SSRI or other Antidepressants?, posted by yxibow on December 13, 2004, at 23:55:40
Hi,
I tried to start a thread about Lepticur but it seems no one has tried it. I think it's only available in France, it is an anticholinergic which is alleged to have fewer peripheral side effects that the rest. Have a look at my post, it might be of interest to you.
Regards,
Ed.
Posted by banga on December 14, 2004, at 8:57:02
In reply to EPS from SSRI or other Antidepressants?, posted by Mr.Scott on December 2, 2004, at 23:52:38
I may have had akathisia and dystonia from cymbalta. I was at a low dose (40mg), and nevertheless felt as thoug my anxiety was worsening.....terrifying (of nothing) to get out of bed. Yet when I mentioned my symptoms to the new pdoc--feeling highly agitated, and my jaw so tense it felt like a vise that was hard to open, she suggested it may in fact be akathisia and dystonia.
I was surprised because it was a low dose, I am not very drug-sensitive....but in general, Cymbalta seemed to not aggree with me, so I guess my body reacted strongly even to this small dose. And indeed, it did feel very physical. It makes sense that these sxs can be mistaken for increased anxiety if you already have anxiety. I wonder if the few other people who mentioned increased anxiety on Cymbalta may have also had something like this going on?
Posted by yxibow on December 14, 2004, at 16:23:11
In reply to Re: EPS from Cymbalta?, posted by banga on December 14, 2004, at 8:57:02
That sounds rather unusual although certainly possible and I empathise... have you ever been on a antipsychotic, especially an old style one (well even a strong atypical like risperdal). Some of these effects are cumulative and can show later. But from what you're saying this was probably a one-off drug experience ?
Posted by olysi79 on December 15, 2004, at 15:49:55
In reply to Re: EPS from SSRI or other Antidepressants? » olysi79, posted by Mr.Scott on December 13, 2004, at 21:34:41
Intense anxiety and restlessness, I'm wondering if it would help for me to try lowering my SSRI
--------------
>
> Can you elaborate? What are your symptoms? Have you called your doctor yet? Don't let it go too long without contacting the doctor.
>
> Scott
Posted by banga on December 15, 2004, at 17:42:44
In reply to Re: EPS from Cymbalta?, posted by yxibow on December 14, 2004, at 16:23:11
This was indeed a one-time, one-drug experience. This did not occur on SSRIs, Effexor, or clomipramine. I have been on short-term, not very high dose regimens of the newer antipsyxhotics, no big problems outside of fatigue and brain fog. The last time I took one (Geodon 40mg) was more than 2 months ago.
When I tried to go up on Cymbalta, the symptoms increased. As soon as I dropped the Cymbalta, the symptoms stopped.
I really think that the cymbalta for some reason simply interacts badly with my chemistry. I was surprised as I expected it to feel like a cleaned-up version of clomipramine, from which I had no side effects at all.
Posted by yxibow on December 17, 2004, at 1:59:36
In reply to Re: EPS from Cymbalta-yxibow?, posted by banga on December 15, 2004, at 17:42:44
> This was indeed a one-time, one-drug experience. This did not occur on SSRIs, Effexor, or clomipramine. I have been on short-term, not very high dose regimens of the newer antipsyxhotics, no big problems outside of fatigue and brain fog. The last time I took one (Geodon 40mg) was more than 2 months ago.
> When I tried to go up on Cymbalta, the symptoms increased. As soon as I dropped the Cymbalta, the symptoms stopped.
> I really think that the cymbalta for some reason simply interacts badly with my chemistry. I was surprised as I expected it to feel like a cleaned-up version of clomipramine, from which I had no side effects at all.I only asked about the AP because under some really unfortunate rare circumstances its cumulative and it shows up later with other drugs. I dont know how long you took the Geodon so I have no data there but I am just gathering you didnt take it for a very long period of time.
Well I again sympathize with your experience, it is obviously different with my experience, I have been on it near since its outset, as have countless people. There are no mentions in PubMed regarding it, but it is a new drug and with all new medications in vivo interactions will still come in. Not to be callous, but it is still possible that the severe anxiety you felt caused the motor disorder itself, even the jaw tightening, that is neither as unknown as Cymbalta causing it (and I'm neither a drug representative nor a doctor here).
I can certainly resonate with drugs reacting badly with chemistry.. a small trial of Zyprexa has left my hands, while better, ever so slightly tremorous inside just enough that I know I can "feel" them. That's something that you wont find in any annals of drug literature for a few weeks of olanzapine.
I would definately expect Cymbalta to be a "cleaned up" version of clomipramine, being a (arguably) 4th class modern antidepressant (tricyclics and MAOIs, SSRIs, Remeron and Effexor and Wellbutrin, etc). But YMMV. If Anafranil worked for you, then try it again... I know it has some nasty sweating problems and other things that trycyclics have. Those are the breaks. On the other hand Anafranil was the first OCD drug and some pop it in the SSRI category.
Perhaps you might want to try Lexapro or Celexa if you haven't already. But I dont know your dx. and dont pretend to be your doctor [insert standard double disclaimer]
Pleasant holidays and I hope things sort out for you
Posted by Mr.Scott on December 17, 2004, at 17:40:45
In reply to Re: EPS from SSRI? To Mr. Scott, posted by ed_uk on December 14, 2004, at 8:02:23
Lepticur.
Thank You! I'll investigate this.
Scott
Posted by Mr.Scott on December 17, 2004, at 17:45:59
In reply to Re: EPS from Cymbalta?, posted by banga on December 14, 2004, at 8:57:02
I had a a very similar experience to you at 30mg of cymbalta. The jaw clenching (bruxism) ought to be a dead give away to any halfwit shrink, but some seem uninformed that this can even happen. It can look like anxiety or even 'dysphoric hypomania', but its really a neurological side effect of the drug taken.I can't wait until the next generation of antidepressants comes of age.
Scott
Posted by banga on December 17, 2004, at 18:35:36
In reply to Re: EPS from Cymbalta? » banga, posted by Mr.Scott on December 17, 2004, at 17:45:59
Yes, with the Cymbalta I at first naturally thought the jaw clenching, agitation and muscle tension were just increased anxiety. Especially since I was weaning off Lexapro as I got on Cymbalta, I just assumed it was withdrawal anxiety. But it persisted, and it would lessen if I decreased the Cymbalta. My former Pdoc didnt catch it; my new one did and informed me that it sounded more like akathisia and dystonia.
Now I am in a bind--I try to wean off that last 20mg of Cymbalta, and I get bad withdrawal--dizziness and brain zaps. I gave up and took 20mg last nigh and--yup, all agitated today. My body hates this drug.
Posted by Mr.Scott on December 20, 2004, at 22:35:00
In reply to Re: EPS from Cymbalta?, posted by banga on December 17, 2004, at 18:35:36
One thing I will add just as a thought is that some of that serotonin mediated stuff (Serotonin decreasing Dopamine) such as akathisia and dystonia could be caused by serotonin overload. By combining two serotoneric drugs like whatever is left in your body of the Lexapro and the Cymbalta maybe it's too much??
Scott
Posted by Cairo on December 21, 2004, at 8:51:20
In reply to Re: EPS from Cymbalta? » banga, posted by Mr.Scott on December 20, 2004, at 22:35:00
I'm convinced of this. I was on 50mg trazodone at night and started 30mg Cymbalta. All the above EPS symptoms began, similar to what I experienced taking only SSRIs, but they were so much more severe. Lowering the dose of Cymbalta to 5mg kept my energy up, decreased anxiety minimally,helped with weight loss, but the EPS symptoms decreased. I went off Cymbalta to try low dose amitriptyline for help with Fibromyalgia pain, but my Pdoc said we might try adding the 5mg Cymbalta back slowly to see what happens. I am extremely sensitive to all SSRIs - Prozac was the worst experience of my life and quitting was hell. I wonder if trazodone contributes to my stiff muscles, even at only 50mg. I want to avoid weight gain with higher doses of amitriptyline, but need the traz along with it for sleep.
Cairo
> One thing I will add just as a thought is that some of that serotonin mediated stuff (Serotonin decreasing Dopamine) such as akathisia and dystonia could be caused by serotonin overload. By combining two serotoneric drugs like whatever is left in your body of the Lexapro and the Cymbalta maybe it's too much??
>
> Scott
Posted by banga on December 21, 2004, at 10:38:44
In reply to Re: EPS from Cymbalta? » banga, posted by Mr.Scott on December 20, 2004, at 22:35:00
Well at this point I have been off of Lexapro for two months (dose was10 mg)...and the dose of Cymbalta was only 40. The first three weeks I could see that to be the case....but the symptoms persisted long after that. Ive been on Lexapro at 15mg combined with 75 mg of Anafranil before and been fine.
My body just hates this drug and overreacts. I am not very med sensitive, just this one clearly doesnt agree with me. Getting off the last 10 mg is very hard for me (brainz zaps), and I usually dont have much of a problem coming off meds, even Paxil and Effexor.
Since I am coming off Cymbalta and never taking it again, on one level I am not so concerned to define precisely what was going wrong while on it. I'm just happy to be off.
Thanks for your responses! And good luck to you.
This is the end of the thread.
Psycho-Babble Medication | Extras | FAQ
Dr. Bob is Robert Hsiung, MD,
bob@dr-bob.org
Script revised: February 4, 2008
URL: http://www.dr-bob.org/cgi-bin/pb/mget.pl
Copyright 2006-17 Robert Hsiung.
Owned and operated by Dr. Bob LLC and not the University of Chicago.