serotonin

serotonin syndrome - know and avoid

Depression Treatment & Serotonin Syndrome – Avoid

Posted on by Michelle Fritsch, Pharm.D.
serotonin syndrome - know and avoid
Avoid serotonin syndrome with careful medication review by doctors and pharmacist.

Last week we reviewed medication treatment of depression and anxiety. Medications impacting serotonin to help regulate mood were a focus. Did you know you could get too much serotonin? When we overdo it, there is a condition called serotonin syndrome that can occur.

I saw a patient that really made me think about this. He is on three antidepressant medications and a couple of other medications that can interact with those. All of them will increase his serotonin levels. I immediately alerted his primary care provider.

Three main scenarios

There are three key ways serotonin syndrome typically occurs:
1. Too many antidepressants, often from more than one doctor. If those doctors don’t know what the others are doing, more than one can start treating the same condition.
2. Self-treatment in addition to prescribed treatment. In particular, St John’s wort increases serotonin. Because there is no regulation for products such as St John’s wort, one bottle can have a different amount than another, so one bottle might lead to too much serotonin while another does not. Several over-the-counter medications can also increase serotonin to dangerously high levels when used with antidepressant medication.
3. Interactions with other medications. There are several other medications for completely different medical conditions that can increase the serotonin effects of antidepressant medications.

Symptoms

When someone has too much serotonin then a condition called serotonin syndrome can occur. The symptoms, especially early on and with a mild version, can be mistaken for a viral illness. These milder symptoms are fever, chills, diarrhea, muscle aches or spasm or rigidity. Other symptoms can be confusion, feeling irritable, or feeling disoriented. Your heart might beat faster and blood pressure could go up.

With more severe serotonin syndrome, seizures, coma, changes in heartbeat, and even unresponsiveness are possible. The most severe cases can lead to death.

Prevent Serotonin Syndrome

Your best defense against serotonin syndrome is to be very open with all of your doctors and your pharmacist about each medication you take. Ask each of them to carefully evaluate your entire regimen.

Do not change your dose on your own. Increasing your dose without guidance increases your risk of serotonin syndrome.

Adding medications you choose to take on your own can increase risk. Medications that can increase serotonin include those you take for cough, for other mood disorders, for pain, for migraine, for nausea, and for some infections. The list is so long, I encourage you to make sure you always share all of your medicines with all of your healthcare providers.

Note, even herbal medications and illicit medications can increase serotonin.

Please don’t be afraid or stop your antidepressant

The purpose of this blog is to make you aware, not to make you afraid. When taken at appropriate doses, antidepressants have aided in the resolution of depression for many people. Keep in mind; counseling is a key part of depression therapy versus medication alone. Keeping your entire medical team involved in each aspect of your care and how you feel during therapy will help avoid issues such as serotonin syndrome.

I want to remind you to never stop your antidepressant/antianxiety medication all of a sudden. Your healthcare team will guide you through a gradual tapered withdrawal when that is warranted.

For information about depression and anxiety treatment, serotonin syndrome, and drug interactions, please contact us at Meds MASH at 410-472-5078 or www.medsmash.com/contact.

BIBLICAL APPLICATION

This might be a loose association, so please stay with me here. I found that people with lingering depression and/or their loved ones seek relief from multiple sources. They sometimes combine prescription medications with herbal therapies with cognitive behavior therapies with religion with any other options for which they find anecdotal evidence. I typically do not hear the full picture at my first visit. It is with time and the building of trust that I get the full story. Sometimes those mixtures of therapies work, and other times they lead to more problems.

I think the same can be true with spiritual growth options. There is a lot of information ‘out there’. You can find speakers, books, videos, churches, ministries, and blogs that will tell you just about anything.

I have mentioned before the rapid growth of para-spiritual businesses that exist to help people feel better. Many of them are quite centered on the person rather than on the One True God.

Discernment is key with so many voices and messages to select. And, wow, this is so much easier to type than to do.

Jesus, Paul, John, Solomon, James, and others throughout the Bible encourage us to be careful. Follow God’s word, follow the leading of the Holy Spirit, and don’t fall for just anything that you hear.

1 John 4:1 ESV

Beloved, do not believe every spirit, but test the spirits to see whether they are from God, for many false prophets have gone out into the world.

I like this passage even better in The Message:

My dear friends, don’t believe everything you hear. Carefully weigh and examine what people tell you. Not everyone who talks about God comes from God. There are a lot of lying preachers loose in the world.

When you’re not sure what you’re hearing is right, take a time out. Go to the Bible. Talk with spiritually mature Christians. Pray for guidance. Hasty decisions can quickly get you into trouble.

James 1:5 ESV

If any of you lacks wisdom, let him ask God, who gives generously to all without reproach, and it will be given him.

You’re smart, but that doesn’t mean you can’t get caught up in false information.

Matthew 24:24 ESV

For false christs and false prophets will arise and perform great signs and wonders, so as to lead astray, if possible, even the elect.

There are so many confusing messages in our World.   Just this past week alone has bombarded you with message of right and wrong and what you should believe.

Romans 12:2 ESV

Do not be conformed to this world, but be transformed by the renewal of your mind, that by testing you may discern what is the will of God, what is good and acceptable and perfect.

Don’t beat yourself up if you’re confused. It is a smart thing to question all you hear, read, see, and experience.

1 Timothy 6:3-5 ESV

If anyone teaches a different doctrine and does not agree with the sound words of our Lord Jesus Christ and the teaching that accords with godliness, he is puffed up with conceit and understands nothing. He has an unhealthy craving for controversy and for quarrels about words, which produce envy, dissension, slander, evil suspicions, and constant friction among people who are depraved in mind and deprived of the truth, imagining that godliness is a means of gain.

Jesus tells us to expect this confusion. He also tells us to be wise, discerning, smart, and loving all at the same time. And HE is the one who can help us do that. You can’t do it alone.

Matthew 10:16 ESV

“Behold, I am sending you out as sheep in the midst of wolves, so be wise as serpents and innocent as doves.

I’m praying we each seek the truth through the One who is and was and is to come.

Blessings,

Michelle

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SSRI dosing

Anxiety and Depression Medications – Step Up, Step Down

Posted on by Michelle Fritsch, Pharm.D.
SSRI dosing
Depression and anxiety medications should be started and later stopped in gradual steps.

Sometimes you can start a medicine and it starts working right away. Sometimes it takes a while to work. Sometimes you can stop a medicine ‘cold turkey.’ Sometimes you can’t without risky side effects. Some require step up and step down dosing.

I believe it is very important to understand a medication, how it works, how to best use it, and how to avoid problems. There are a lot of these tidbits that are important in the use of anxiety/depression medications. The most commonly used anxiety/depression medications right now are in a class called ‘selective serotonin reuptake inhibitors’ (SSRIs).

The class name describes how they work. I’m going to try to break it down into steps that make sense.

Neurotransmitters

The first step is to have some understanding of neurotransmitters. They are the brain’s messengers. They carry messages from one nerve to another.

Some of the main neurotransmitters are:

  • Epinephrine – adrenalin, drives the sympathetic system and your ‘fight or flight’ response when you are scared, in stress, or in danger
  • Norepinephrine – also drives the sympathetic system causing you to feel awake, ready for the day, able to manage stress
  • Dopamine – mainly related to movement; increasing this is key in the treatment of Parkinson’s Disease
  • Serotonin – manages your mood, appetite, sleep, and movement of your gastrointestinal tract

Neurotransmitters are passed from nerve cell to nerve cell. As a neurotransmitter leaves one nerve cell, it goes into a space between the end of that nerve cell and the beginning of the next nerve cell. This space is called the synapse.

The beginning of the next nerve cell has receptors.   Neurotransmitter in the synapse (the space) will bind to a receptor. That will allow it to get into the nerve cell and create an electrical signal that will travel through it to the end and continue the message to the next neuron in the same manner. At the end, it will be released into the synapse where it can be picked up by the receptors of the next nerve cell. In this way, the message travels through the whole nerve system.

When there is too much neurotransmitter in the synapse, the nerve cell that released it can take it back. This is called reuptake.

The body has amazing processes to regulate itself. In this case, release from a nerve cell, time in the synapse, and binding to a receptor in the next nerve cell are all carefully synchronized.

Serotonin, depression, and anxiety

Serotonin is one of the primary neurotransmitters for the regulation of mood and sleep. When someone is depressed, it might be because serotonin transmissions are too slow.

When someone is experiencing anxiety, serotonin levels might be out of balance.

The role of selective serotonin reuptake inhibitors is to prevent the first nerve cell from taking back the extra serotonin it has released. This will make more serotonin available for the receptor of the next nerve cell. This will allow more serotonin to be passed from nerve cell to nerve cell.

Product delivery analogy

Imagine you have created a product that is a popular gift for special occasions. During most months the demand for your product stays steady for events such as birthdays.

On these months, you keep a regular supply of product in your warehouse. Ten distribution trucks can get the products to the stores that sell your product. This keeps the stores supplied with enough product for customers each month. If a store has several products that have not sold, they will send them back to the warehouse in the delivery truck.

Then, there are two months when the demand goes way up. During these two months, you stock your warehouse with much more product. You hire 10 more distribution trucks. You stop taking any product back to the warehouse from the stores. All product is moved from the warehouse to the stores.

Then, in the month after the rush, demand gradually decreases. It does not immediately go back to normal. People exchanging gifts often exchange their original gift for your product. Others see their friends with your product and want one for themselves. Then eventually, the demand is back to normal.

In this analogy, your product is the serotonin. The warehouse is the nerve cell that stores the serotonin. The delivery truck is the receptor that will transport the serotonin into the next nerve cell to continue the message.

Why Step Up and Step Down?

Increasing the availability of serotonin takes time. The nerve cells can’t immediately stop the reuptake process. The receptors don’t immediately increase in number to use more of the available serotonin. The entire central nervous system doesn’t immediately respond to the extra serotonin. That whole process takes about 8 weeks. At around 4 weeks the doctor prescribing the SSRI might increase the dose if your energy is not starting to pick up.

Similarly, it takes time for the body to adapt when the medication is stopped. Usually, if someone with a first episode of depression has been treated for six months and is feeling good, then the SSRI can be stopped. However, it shouldn’t be stopped all at once. It will again take the nervous system time to adapt to a change in the medication. So, the dose needs to be very gradually decreased over a few weeks. If it is stopped all at once you could feel dizzy, tired, anxious, achy, irritable, nauseous, like your skin is prickly, or other symptoms. The receptors and nerve cells need time to take back over the serotonin transmission without assistance.

NOTE, this does not mean you are addicted. It means your body has adapted to the medication and needs time to adapt back to being without the medicine.

Disclaimers – Everyone will have times in life with highs and lows. Each low is not a type of depression that requires treatment. A professional makes the diagnosis of depression or anxiety requiring treatment. The treated depression or anxiety has usually lasted several weeks to months and is impacting daily life activities.

If this leaves you with questions, please contact us at Meds MASH at 410-472-5078 or www.medsmash.com/contact.

BIBLICAL APPLICATION

The step therapy of SSRI’s reminds me a common path of helping other people find Christ.

Often someone who doesn’t know Christ will hesitate to find an accept Him all at once. Sometimes it is years of small events, people, exposures, or discussion that gradually lead to real interest. Even from there, developing understanding and real seeking can take more time. At some point after all of this exposure and searching, the person reaches the point of accepting Christ and moves to leading a life of following Christ. As a believer in that person’s life, you can’t just wash your hands and walk away. This new believer is in a fragile state. The excitement, joy, and intentions are very real. Do you remember how awesome that time period was, if you are a believer who came to Christ over a period of time of searching? If you walk away now, that new believer could be like the seed that falls on rocky ground from the Parable of the Sower.

Matthew 13:5-6 ESV

Other seeds fell on rocky ground, where they did not have much soil, and immediately they sprang up, since they had no depth of soil, but when the sun rose they were scorched. And since they had no root, they withered away.

Jesus goes on to explain this parable (found Matthew 13:1-23), and the explanation of this part is:

Matthew 13:20-21 ESV

As for what was sown on rocky ground, this is the one who hears the word and immediately receives it with joy, yet he has no root in himself, but endures for a while, and when tribulation or persecution arises on account of the word, immediately he falls away.

Following Christ can seem so obvious, so right, so easy at first.   But, life is full of road bumps, dead ends, and hardship. A brand new believer can quickly and easily become disillusioned. You know Satan will be lining up these difficulties to create just this situation. So, you can’t just walk away and feel that your work is done.

Support for a new believer is at least as important as helping others find Christ.

As the new believer learns to communicate, read God’s word and listen for His voice, and find friendships with other believers, then your role will gradually be less critical. It doesn’t go away, but the frequency of your interactions might decrease.

The role of continued fellowship and connection with other believers is found throughout the Bible.

Romans 1:12 ESV

That is, that we may be mutually encouraged by each other’s faith, both yours and mine.

1 Thessalonians 5:11 ESV

Therefore encourage one another and build one another up, just as you are doing.

Hebrews 10:25 ESV

Not neglecting to meet together, as is the habit of some, but encouraging one another, and all the more as you see the Day drawing near.

So, I found it interesting to consider how we step up when introducing someone to Christ and step down as they grow and mature in their faith.

Blessings,

Michelle