Ask Your Metafilter If Zoloft Is Right For You
August 31, 2013 4:46 PM Subscribe
You are not my doctor. I have a doctor, and clinical depression. Am I not tolerating the Zoloft he prescribed? Is it not working? Snowflakes inside.
I got hit with a slew of serious life challenges, which turned into clinical depression. Some of the challenges I have overcome, others not, but the depression has set in like a black cloud.
My doctor prescribed Cipralex, which left me feeling like I had a bad case of the flu. So after two pills and two days, I stopped it.
The good doctor went off on vacation after that, so I started taking St. John's Wort, an herbal SSRI. It immediately improved my frame of mind. As in, I started feeling better within hours.
I found that if I took roughly double the recommended dose (5 x 300 mg a day, instead of 3 a day, spaced every 4-5 hours or so), I would sometimes feel like a normal human being. But the feeling wasn't reliable, which I chalk up to it being an herbal supplement. And the bottle says not to take it for more than six weeks.
So, when the doc came back, he gave me a prescription of Zoloft. (2 x 25 mg/day). I've spent three days with a bad combination of wooziness (that fluish feeling again) and depression.
I know SSRI's are supposed to take weeks to kick in, but that's never been true of the St. John's Wort. And feeling physically ill does not help with the emotional challenge of depression.
So, questions:
a. Does three days of feeling like I've got the flu qualify as "not tolerating" the Zoloft?
b. If St. John's Wort kicks in right away, is that a sign the Zoloft isn't working?
c. Any reason I shouldn't just stick with the herbs, even though they're not well regulated?
d. Am I endangering myself by taking more than the recommended dosage of the herbs?
I got hit with a slew of serious life challenges, which turned into clinical depression. Some of the challenges I have overcome, others not, but the depression has set in like a black cloud.
My doctor prescribed Cipralex, which left me feeling like I had a bad case of the flu. So after two pills and two days, I stopped it.
The good doctor went off on vacation after that, so I started taking St. John's Wort, an herbal SSRI. It immediately improved my frame of mind. As in, I started feeling better within hours.
I found that if I took roughly double the recommended dose (5 x 300 mg a day, instead of 3 a day, spaced every 4-5 hours or so), I would sometimes feel like a normal human being. But the feeling wasn't reliable, which I chalk up to it being an herbal supplement. And the bottle says not to take it for more than six weeks.
So, when the doc came back, he gave me a prescription of Zoloft. (2 x 25 mg/day). I've spent three days with a bad combination of wooziness (that fluish feeling again) and depression.
I know SSRI's are supposed to take weeks to kick in, but that's never been true of the St. John's Wort. And feeling physically ill does not help with the emotional challenge of depression.
So, questions:
a. Does three days of feeling like I've got the flu qualify as "not tolerating" the Zoloft?
b. If St. John's Wort kicks in right away, is that a sign the Zoloft isn't working?
c. Any reason I shouldn't just stick with the herbs, even though they're not well regulated?
d. Am I endangering myself by taking more than the recommended dosage of the herbs?
For a lot of people, the side effects diminish over time, and the antidepressant effects build up over time. It's really common to have unpleasant side effects your first few weeks, and then to have them fade after that. That's true even for people who antidepressants end up working really well for.
Give it a few weeks before you give up on the Zoloft.
posted by Now there are two. There are two _______. at 4:57 PM on August 31, 2013 [1 favorite]
Give it a few weeks before you give up on the Zoloft.
posted by Now there are two. There are two _______. at 4:57 PM on August 31, 2013 [1 favorite]
Seconding that you need to give it at least two weeks for the side effects (which often include dizziness, nausea, and anxiety) to fade and the effectiveness to increase.
Your St. John's Wort experience sounds more like placebo effect than anything else.
posted by jaguar at 5:01 PM on August 31, 2013 [5 favorites]
Your St. John's Wort experience sounds more like placebo effect than anything else.
posted by jaguar at 5:01 PM on August 31, 2013 [5 favorites]
The side effects that you have described sound normal. They usually occur while your body is getting used to the drug. They are supposed to go away after a week or so. Some people have side effects for a longer period of time.
posted by dfriedman at 5:14 PM on August 31, 2013 [1 favorite]
posted by dfriedman at 5:14 PM on August 31, 2013 [1 favorite]
It's not clear to me from your question, but if you are currently taking St. John's Wort along with your new prescription for Zoloft, don't.
http://umm.edu/health/medical/altmed/herb-interaction/possible-interactions-with-st-johns-wort
You're not going to know whether or not the Zoloft is working until you've been on >50mg daily dose for several weeks. Please give it time.
posted by trunk muffins at 5:28 PM on August 31, 2013 [1 favorite]
http://umm.edu/health/medical/altmed/herb-interaction/possible-interactions-with-st-johns-wort
You're not going to know whether or not the Zoloft is working until you've been on >50mg daily dose for several weeks. Please give it time.
posted by trunk muffins at 5:28 PM on August 31, 2013 [1 favorite]
Best answer: I've been on Effexor a few times, and I found that CrazyMeds has good info geared to non-expert patients trying to make informed decisions about psychiatric drug treatments.
On your specific questions:
(a) On 3 days of side effects when starting a new drug: The first week of any drug doesn't tell you much about most anti-depressants, and initial side effects are normal and usually calm down within a few weeks. It takes a while for your body to adjust to any drug, and your doctor is likely starting you on a low dose and will gradually increase it until you reach a clinically effective dose. They don't start you on the high dose because you have to acclimate to the drug first. No, it isn't fun. Yes, it can be worth it.
Your depression didn't set in right away. It's not going to dissipate right away, even if you find the perfect drug. Think of it like a broken leg: Even with the best treatment, it takes time to heal. Maybe your leg is crazy-itchy in its cast, but it's worth it, right? Maybe you feel dizzy or seasick for the first few weeks on an SSRI, but it could be a good fit anyways. Give it time. Really.
(b) On how long it takes to react to a drug: You know, every med is different and every person is different. I happen to be a person who reacts very quickly to a very low dose of Effexor. I'm way on one end of the bell curve. However, that doesn't mean that I would necessarily react so quickly to something else. Most psych meds require at least a few weeks to work their way into your system. Each dose of Zoloft stays in your system for 5–6 days (this is different for every drug), so when you're taking it every day the different doses are overlapping. At 3 days, you're not at the level that you will be at after 2 weeks. You need to give your body time to adjust to it and for the dose to gradually ramp up in your system.
(c) On sticking with St. John's Wort: You're not mixing St. John's Wort with the Zoloft, right? Because that's not a fantastic idea. And St. John's Wort is not an SSRI; it has some similar effects but it is not the same thing. When you mix things they can interact badly, especially a regulated thing with an unregulated unpredictable thing that we don't understand nearly as well.
If St John's Wort is not working for you reliably, I wouldn't stick with it. The dosages are not very predictable, and that can cause a lot of up-down-up-down nonsense that I would personally not be comfortable relying on.
(d) On higher-than-recommended dosages of St. John's Wort: Yes, this is likely a bad idea. St. John's Wort is a real chemical thing that has real side effects and much less pharma research money behind it, so there haven't been as many studies. For example, we know that it is a bad bad bad idea to mix it with hormonal birth control (which I realize you are not on, but I am mentioning it as a concrete example). 'Natural' doesn't mean 'this won't have an effect on the body's ecosystem'. You're taking it because you hope it will effect your body's ecosystem so the depression will lift. Logically, that would also change the environment the Zoloft is working in, and maybe not in the way you would hope.
Generally it's best to change one thing at a time so you can figure out what's working and what's not.
Best of luck. It is great that you are taking steps to fight the depression — choosing to go on meds is not easy! I wish I could tell you that there's a fast easy fix for it, but in my experience our brains respond better to gradual shifts.
posted by heatherann at 5:37 PM on August 31, 2013 [13 favorites]
- Tips on Taking Meds
- Side Effects All Psychiatric Drugs Have
- Overview of how SSRIs work
- Tons of info on Zoloft: how it works, what it's like to start on it, how to get off it, side effects
- Info on Cipralex / Lexapro
- CrazyMeds discussion with info on St John's Wort
On your specific questions:
(a) On 3 days of side effects when starting a new drug: The first week of any drug doesn't tell you much about most anti-depressants, and initial side effects are normal and usually calm down within a few weeks. It takes a while for your body to adjust to any drug, and your doctor is likely starting you on a low dose and will gradually increase it until you reach a clinically effective dose. They don't start you on the high dose because you have to acclimate to the drug first. No, it isn't fun. Yes, it can be worth it.
Your depression didn't set in right away. It's not going to dissipate right away, even if you find the perfect drug. Think of it like a broken leg: Even with the best treatment, it takes time to heal. Maybe your leg is crazy-itchy in its cast, but it's worth it, right? Maybe you feel dizzy or seasick for the first few weeks on an SSRI, but it could be a good fit anyways. Give it time. Really.
(b) On how long it takes to react to a drug: You know, every med is different and every person is different. I happen to be a person who reacts very quickly to a very low dose of Effexor. I'm way on one end of the bell curve. However, that doesn't mean that I would necessarily react so quickly to something else. Most psych meds require at least a few weeks to work their way into your system. Each dose of Zoloft stays in your system for 5–6 days (this is different for every drug), so when you're taking it every day the different doses are overlapping. At 3 days, you're not at the level that you will be at after 2 weeks. You need to give your body time to adjust to it and for the dose to gradually ramp up in your system.
(c) On sticking with St. John's Wort: You're not mixing St. John's Wort with the Zoloft, right? Because that's not a fantastic idea. And St. John's Wort is not an SSRI; it has some similar effects but it is not the same thing. When you mix things they can interact badly, especially a regulated thing with an unregulated unpredictable thing that we don't understand nearly as well.
If St John's Wort is not working for you reliably, I wouldn't stick with it. The dosages are not very predictable, and that can cause a lot of up-down-up-down nonsense that I would personally not be comfortable relying on.
(d) On higher-than-recommended dosages of St. John's Wort: Yes, this is likely a bad idea. St. John's Wort is a real chemical thing that has real side effects and much less pharma research money behind it, so there haven't been as many studies. For example, we know that it is a bad bad bad idea to mix it with hormonal birth control (which I realize you are not on, but I am mentioning it as a concrete example). 'Natural' doesn't mean 'this won't have an effect on the body's ecosystem'. You're taking it because you hope it will effect your body's ecosystem so the depression will lift. Logically, that would also change the environment the Zoloft is working in, and maybe not in the way you would hope.
Generally it's best to change one thing at a time so you can figure out what's working and what's not.
Best of luck. It is great that you are taking steps to fight the depression — choosing to go on meds is not easy! I wish I could tell you that there's a fast easy fix for it, but in my experience our brains respond better to gradual shifts.
posted by heatherann at 5:37 PM on August 31, 2013 [13 favorites]
Rule of thumb, two months. If you feel nothing, zip, after the first month at a low dose, then the Dr. takes it up to the next dose and you try that for a month.
What you're looking for, in my experience--though of course YMMV--is that one day you notice, while thinking of something totally different, that you actually don't feel as awful as you used to. I was watching the water go down the bathtub drain one time when I realized that, hey, that breakup didn't hurt as much as it had. Or you'll notice that you haven't thought about killing yourself for, what, at least 12 hours.
posted by skbw at 5:49 PM on August 31, 2013 [4 favorites]
What you're looking for, in my experience--though of course YMMV--is that one day you notice, while thinking of something totally different, that you actually don't feel as awful as you used to. I was watching the water go down the bathtub drain one time when I realized that, hey, that breakup didn't hurt as much as it had. Or you'll notice that you haven't thought about killing yourself for, what, at least 12 hours.
posted by skbw at 5:49 PM on August 31, 2013 [4 favorites]
I have taken SSRIs a few times (not Zoloft). It takes about two weeks for the side effects to go away, which they reliably do. I then find about three days after the side effects have gone, I wake up one morning feeling miraculously normal again, mood-wise.
My husband has also taken them, and he finds side affects only last about a week (or less) and that the mood improvements are gradual, but take up to a month to establish themselves strongly enough that he is sure the meds are doing something.
Everyone's experience differs, but I don't know anyone who found two or three days were long enough to know how they would tolerate a SSRI or whether it would help the depression.
posted by lollusc at 8:19 PM on August 31, 2013 [2 favorites]
My husband has also taken them, and he finds side affects only last about a week (or less) and that the mood improvements are gradual, but take up to a month to establish themselves strongly enough that he is sure the meds are doing something.
Everyone's experience differs, but I don't know anyone who found two or three days were long enough to know how they would tolerate a SSRI or whether it would help the depression.
posted by lollusc at 8:19 PM on August 31, 2013 [2 favorites]
Best answer: Back when I was on antidepressants, my SSRI didn't do enough for me so my psych doc supplemented it with bupropion (Wellbutrin). That made a HUGE difference.
posted by Jacqueline at 2:07 AM on September 1, 2013
posted by Jacqueline at 2:07 AM on September 1, 2013
A. No
B. No
C No
D I beleive St Johns Wort is a first line approach in Germany, you may find more detailed guidance on dosage, based on research on german websites.
posted by BenPens at 2:34 AM on September 1, 2013
B. No
C No
D I beleive St Johns Wort is a first line approach in Germany, you may find more detailed guidance on dosage, based on research on german websites.
posted by BenPens at 2:34 AM on September 1, 2013
I am not remotely a doctor, but logically unless St Johns Wort is the active ingredient in Zoloft then how quickly you react to it does not tell you anything about whether Zoloft will work for you.
Anecdotally nthing what others have said - people I know on Zoloft did not enjoy the side effects at the start, but it gets better.
posted by puffmoike at 5:33 AM on September 1, 2013
Anecdotally nthing what others have said - people I know on Zoloft did not enjoy the side effects at the start, but it gets better.
posted by puffmoike at 5:33 AM on September 1, 2013
Please don't take this the wrong way, but I'm a bit concerned that of two responses you've marked as a good answer one was a short response about yet another drug.
The majority of the earlier answers have suggested that you need to be on Zoloft for a few weeks before you can determine if it is effective. You've only been on it for three days.
At this point you need to trust your doctor. He or she will help you make the best decisions to get on top of your depression. You're in no place to be trying to make those decisions yourself, even with the well-meaning advice of the MeFi community.
posted by puffmoike at 5:49 AM on September 1, 2013 [2 favorites]
The majority of the earlier answers have suggested that you need to be on Zoloft for a few weeks before you can determine if it is effective. You've only been on it for three days.
At this point you need to trust your doctor. He or she will help you make the best decisions to get on top of your depression. You're in no place to be trying to make those decisions yourself, even with the well-meaning advice of the MeFi community.
posted by puffmoike at 5:49 AM on September 1, 2013 [2 favorites]
Best answer: What follows is a post from my current state of knowledge - I read a lot on this subject relating to my own experience but my understanding is always evolving. (I'm a scientifically literate rationalist, for the record.) Also a post from not quite enough coffee/wakefulness.
In all cases, what's happened is I've gained more knowledge after taking the drug, therefore specific expectation effects don't strongly come into play here.
Zoloft and Cipralex are pretty straight SSRIs as far as I know, and for me they've never been very effective at all, regardless of dosage. Prozac is also categorized as a SSRI, but it's recently been discovered that it has wider effects (need to dig out the reference here). Prozac's been the only antidepressant which really gave me a lift and helped me feel like a normal person, and completely changed my view of what 'efficacy' meant in an antidepressant, because previously I'd thought I just hadn't been trying hard enough. I genuinely felt the difference after a week at the right dosage, and for me 'feeling the difference' meant waking up every day with the thought 'oh, this is how normal people feel every day!'. Taking the other SSRIs was like taking cardboard in comparison.
I've also been prescribed Remeron, which broke after a week. It's a NaSSA/tetracyclic. It's also a mild psychedelic, so I spent the week gently out of myself but still mostly depressed, and once the trip ended I just had the depression and the desire to eat a lot.
The reason I'm giving this background is that I don't think your better response to St John's Wort is simply placebo - I had a quick read around the specs of it just now, and it seems to be a herbal preparation that works chemically on several fronts, which reminded me very much of my experience with Prozac. Ongoing mainstream research is finding the brain to be subtle and not respond in ways according with previous simplistic hypotheses about depression (especially the serotonin hypothesis) and other mental health concerns which can be treated pharmacologically. If I were your doctor I'd try Prozac next on my experience of what's happened with my patients (me!), and continue exploring other options, because I find your response to the herb really interesting and promising. I would be wary regarding long-term usage and investigate the safety concerns - as you're doing.
Do talk with your doctor. Don't go rogue! Work with them, and when you can't get an appointment with the good doctor, it's usually okay to follow the less-good one's prescriptions/advice for a week or two (two weeks is my maximum) unless they're suggesting something drastic OR you're having serious depressive thoughts which need immediate, effective medical intervention. Do also discuss with them about how long one should tolerate side effects. Try mood tracking for an objective measure that digs beneath how the side effects themselves are making you feel - I've used moodscope.com effectively in the past. What I wish I'd been able to understand earlier in my illness, and something which GPs and psychiatrists with their limited(!) experience (I know there are good psychiatrists out there, but mine specifically was not good at all on the medication front, or any front) weren't able to tell me confidently, is that I do genuinely deserve a drug that works, and that that is possible. You've got something to work from here, and that's fantastic.
posted by lokta at 6:36 AM on September 1, 2013
In all cases, what's happened is I've gained more knowledge after taking the drug, therefore specific expectation effects don't strongly come into play here.
Zoloft and Cipralex are pretty straight SSRIs as far as I know, and for me they've never been very effective at all, regardless of dosage. Prozac is also categorized as a SSRI, but it's recently been discovered that it has wider effects (need to dig out the reference here). Prozac's been the only antidepressant which really gave me a lift and helped me feel like a normal person, and completely changed my view of what 'efficacy' meant in an antidepressant, because previously I'd thought I just hadn't been trying hard enough. I genuinely felt the difference after a week at the right dosage, and for me 'feeling the difference' meant waking up every day with the thought 'oh, this is how normal people feel every day!'. Taking the other SSRIs was like taking cardboard in comparison.
I've also been prescribed Remeron, which broke after a week. It's a NaSSA/tetracyclic. It's also a mild psychedelic, so I spent the week gently out of myself but still mostly depressed, and once the trip ended I just had the depression and the desire to eat a lot.
The reason I'm giving this background is that I don't think your better response to St John's Wort is simply placebo - I had a quick read around the specs of it just now, and it seems to be a herbal preparation that works chemically on several fronts, which reminded me very much of my experience with Prozac. Ongoing mainstream research is finding the brain to be subtle and not respond in ways according with previous simplistic hypotheses about depression (especially the serotonin hypothesis) and other mental health concerns which can be treated pharmacologically. If I were your doctor I'd try Prozac next on my experience of what's happened with my patients (me!), and continue exploring other options, because I find your response to the herb really interesting and promising. I would be wary regarding long-term usage and investigate the safety concerns - as you're doing.
Do talk with your doctor. Don't go rogue! Work with them, and when you can't get an appointment with the good doctor, it's usually okay to follow the less-good one's prescriptions/advice for a week or two (two weeks is my maximum) unless they're suggesting something drastic OR you're having serious depressive thoughts which need immediate, effective medical intervention. Do also discuss with them about how long one should tolerate side effects. Try mood tracking for an objective measure that digs beneath how the side effects themselves are making you feel - I've used moodscope.com effectively in the past. What I wish I'd been able to understand earlier in my illness, and something which GPs and psychiatrists with their limited(!) experience (I know there are good psychiatrists out there, but mine specifically was not good at all on the medication front, or any front) weren't able to tell me confidently, is that I do genuinely deserve a drug that works, and that that is possible. You've got something to work from here, and that's fantastic.
posted by lokta at 6:36 AM on September 1, 2013
Please don't take this the wrong way, but I'm a bit concerned that of two responses you've marked as a good answer one was a short response about yet another drug.
I'll second this.
You marked my previous answer as a best answer, and I was serious about this part: Only change one thing at a time.
Like, only one thing a month at most. This month you're trying Zoloft. No St. John's Wort, no pushing for Wellbutrin. Give your body a chance to tell you how it feels after getting used to Zoloft. Let the flu-like symptoms subside. If, after a month to 6 weeks of taking Zoloft as recommended, your body tells you "this isn't lifting the cloud", then change ONE thing. Maybe that one thing is coming off the Zoloft. Maybe it's adding Wellbutrin. Maybe it's switching to Prozac. But just do one at a time, and let your doctor help you figure out which thing to try each month.
As I said before: With brains, gradual changes are best. Be gentle with your brain.
If you want to track how things feel each day, a tool like Patients Like Me could be helpful. This can help you be gentle, because then you can see how your mood and side effects are changing over weeks and months rather than making abrupt decisions because you feel really shitty today. It's like when you're trying to lose weight — maybe your weight is 1 pound higher this week but 10 pounds lower over the last 3 months. Make your decisions based on 3-month data patterns.
posted by heatherann at 6:57 AM on September 1, 2013 [6 favorites]
I'll second this.
You marked my previous answer as a best answer, and I was serious about this part: Only change one thing at a time.
Like, only one thing a month at most. This month you're trying Zoloft. No St. John's Wort, no pushing for Wellbutrin. Give your body a chance to tell you how it feels after getting used to Zoloft. Let the flu-like symptoms subside. If, after a month to 6 weeks of taking Zoloft as recommended, your body tells you "this isn't lifting the cloud", then change ONE thing. Maybe that one thing is coming off the Zoloft. Maybe it's adding Wellbutrin. Maybe it's switching to Prozac. But just do one at a time, and let your doctor help you figure out which thing to try each month.
As I said before: With brains, gradual changes are best. Be gentle with your brain.
If you want to track how things feel each day, a tool like Patients Like Me could be helpful. This can help you be gentle, because then you can see how your mood and side effects are changing over weeks and months rather than making abrupt decisions because you feel really shitty today. It's like when you're trying to lose weight — maybe your weight is 1 pound higher this week but 10 pounds lower over the last 3 months. Make your decisions based on 3-month data patterns.
posted by heatherann at 6:57 AM on September 1, 2013 [6 favorites]
Honestly, some people just don't respond to Zoloft. I didn't, not at all. No side effects, no nothing. And even the SSRIs I responded to didn't really work for my depression. Wellbutrin worked. And I agree with the other people who are against the St. John's Wort. Too many variables, not enough research. And a lot of bad interaction possibilities that could be dangerous in an emergency. Not to mention high probability of sun sensitivity.
If someone else who knows you and has seen you at your worst thinks you are doing better after a month of Zoloft (or any drug), it is probably working. Even if you haven't noticed it. If not, might be time to ask about adding or transitioning to something else.
I know it would be nice to have it gone right now, but depression usually doesn't go that fast. It took years for me to find meds that work, and serious promises to my mother and therapist not to self-harm to keep me from finding relief that way. But if you keep at it, keep looking for something that will help, you have a much better likelihood of finding it.
posted by monopas at 12:33 PM on September 1, 2013
If someone else who knows you and has seen you at your worst thinks you are doing better after a month of Zoloft (or any drug), it is probably working. Even if you haven't noticed it. If not, might be time to ask about adding or transitioning to something else.
I know it would be nice to have it gone right now, but depression usually doesn't go that fast. It took years for me to find meds that work, and serious promises to my mother and therapist not to self-harm to keep me from finding relief that way. But if you keep at it, keep looking for something that will help, you have a much better likelihood of finding it.
posted by monopas at 12:33 PM on September 1, 2013
One caution with St. john's Wort...it has been found to DECREASE the effectiveness of other drugs you may be taking. a German study found women taking st. john's with birth control pills had a disturbingly high rate of pregnancy! Even if you are not on other meds now..what if you suddenly need to be? You would not want to risk them not working!
posted by Lylo at 7:50 PM on September 1, 2013
posted by Lylo at 7:50 PM on September 1, 2013
You may also want to get your B12 levels checked: http://www.health.harvard.edu/blog/vitamin-b12-deficiency-can-be-sneaky-harmful-201301105780
If that's the culprit in the depression, getting your levels back up is a lot cheaper, easier, and less dangerous and side-effect prone (and less prone to future "withdrawal syndrome") than medication.
posted by jenh at 8:34 AM on September 2, 2013
If that's the culprit in the depression, getting your levels back up is a lot cheaper, easier, and less dangerous and side-effect prone (and less prone to future "withdrawal syndrome") than medication.
posted by jenh at 8:34 AM on September 2, 2013
This thread is closed to new comments.
I also took Celexa for a week and it made me feel extremely groggy so my last doc switched me over to Zoloft right away. I've never taken St John's Wort.
posted by tigeri at 4:53 PM on August 31, 2013