When do I move on to the next stage to eliminate the panic?

December 10, 2013 11:12 AM

I've been on 20mg of citalopram (Celexa) for about 10 days and I actually feel worse. At what point should I start CBT OR at what point should I complain to my GP?

I've always had a bit of a problem with anxiety and the occasional panic attack, but over the past few months it's been worse (3-4 panic attacks within about 4-6 weeks). I went to a new GP for the first time and he put me on 20mg of citalopram. Blood tests (for liver, glucose, thyroid, bone-something, and 2 other things came back normal).

I have read many places that if citalopram is to be prescribed for panic disorder, the usual thing to do is start at 10mg and work up to 20mg a week or so later, and further if need be. I have also read that when one starts taking citalopram for panic disorder, one is likely to experience more anxiety/panic/related symptoms in the initial settling in period before the beneficial effects start to be felt (I assume this is why it's normal to start at 10mg).

So...that is where I am now, feeling on the edge of a panic attack in situations where I used to only feel a little anxious. Occasionally stuttering when I would previously only stutter under extreme stress. Occasional tremor in the hand, totally new. And more, on top of staying in bed and napping away a lot of the day. Assuming I'll get over this in 1-3 weeks. Hoping it's sooner rather than later.

I have read that overcoming (or learning to live with) panic disorder (or high anxiety, or whatever) takes medication and therapy (usually CBT). Should I start ASAP? Or wait until my anxiety levels are brought back down to what they were when I started the citalopram?

And...given that it's predictable to feel worse before I feel better on the citalopram, at what point (3 weeks? 5?) should I return to my GP and possibly say 'hey, this doesn't seem to be working'? When should I stop just hanging on and actually ask the question if these are the right meds for me?

Throwaway email is [e-mail]

posted by anonymous to Health & Fitness (13 answers total)

Check in with your doc.
posted by luckynerd at 11:22 AM on December 10, 2013 [2 favorites]

Feeling edgy, sleepy, having tremors - that's more or less par for the course when starting an SSRI. 10 days really isn't enough time. In my experience, the nasty side effects tend to level off after a month or so. I would probably give the meds at least 5 weeks before talking to your doc about it.

I also recommend talking to a psychiatrist about your meds. GPs are okay in a pinch, but a PDoc would probably have started you at a lower dose and ramped you up over time, and seen you a couple times in there to check in. I wouldn't worry about starting at the 20mg, but the side effects are going to seem more intense than starting at a lower dose for sure.

If it continues to be awful, escitalopram (Lexapro) is a very similar drug to celexa, but was developed in part to make a drug with fewer side effects. It might be worth asking about. Celexa and Lexapro are very successful treatments for anxiety. So I think you're on the right path. Try to stick with it.
posted by Lutoslawski at 11:24 AM on December 10, 2013 [3 favorites]

Oh, and CBT is a great idea. Most PDocs I've worked with will get you started and happy with the drugs first and then start therapy. That always made sense to me because it's easier to approach the CBT once the drugs have sort of taken care of the worst of it.
posted by Lutoslawski at 11:25 AM on December 10, 2013 [1 favorite]

I would give it 2-4 weeks. Celexa really helped me with my panic attacks. I was also given xanax as needed until the Celexa kicked in. CBT also helped but mainly with my social anxiety and depression.
While on 20mg Celexa, I didn't need the xanax and didn't have a panic attack for 9 years or so. Then they came back and I'm starting a new SSRI and going through the trial like you. Hang in there.
posted by KogeLiz at 11:27 AM on December 10, 2013

I'd also suggest 2-3 weeks. In my experience, the worst of the anxiety fades after about two weeks, and the remaining jitteriness fades in another week or two.

In many cases and anecdotally, initial increases in anxiety can indicate that the medication will actually work very well to decrease anxiety long-term.

Many doctors prescribe some sort of benzo along with a new prescription for SSRIs, specifically to help patients get through the initial upsurge in anxiety. I would talk to your doctor ASAP about whether that's a possibility for you, given the side effects you're experiencing. You might even be able to get that done over the phone, without having to go back in.

You can start therapy at any time! A therapist who's good with managing medications might have other suggestions for you during this time, or can at least let you know what's normal vs. what might indicate the medication's not working properly. If you want to wait, that's fine, but don't feel you need to be at any particular level of functioning in order to start therapy.
posted by jaguar at 11:33 AM on December 10, 2013

Just a note: I've been on both Citalopram (Celexa) and Escitalopram (Lexapro), and 20mg is the usual starting dose for Citalopram, so in looking this up online you may have been reading sites referring to Escitalopram instead. As Lutoslawski mentions, these are actually the same drug, but Escitalopram is a newer version - most simply, Citalopram contains about 50% of the active drug molecule and 50% of an inactive mirror-image molecule, while Escitalopram contains only the active drug molecule, and so has the same effectiveness at about half the dose.

Anyway, for Citalopram, 20mg is a fairly small dose, so in your case I wouldn't worry much about side effects. Along with the other posters, the first time I started taking SSRIs, it took 3-4 weeks until I really felt a decrease in my anxiety. The best thing you can do is check in with your doctor, who should be able to help you figure out if what you're feeling is normal adjustment, and if not could work with you to adjust your treatment.
posted by augustimagination at 11:43 AM on December 10, 2013

Short answer first: You certainly should go ahead and give CBT a try now. And talk to your doc now about the increased anxiety. There is absolutely no need to wait to ask about it, and no particular benefit in doing so.

The longer answer is, the increased anxiety is not necessarily due to the med, and it wouldn't be possible for the doctor to untangle the cause of the increased anxiety, and even if it were due to the med, that wouldn't necessarily imply it wouldn't start working for you in another week or so. So sticking with the citalopram at the current dose is an option. Adding something a little calming to the regimen may also be an option (and in fact I'm kind of surprised you weren't already given a tranquilizer, but maybe the doc holds off on those except for more frequent attacks?).

Something I would recommend avoiding, though, is jumping from SSRI to SSRI (or other class of antidepressant) in a short period of time. It muddies the water, making it harder to figure out what might work and what doesn't, sorting out side effects, increasing the possibility of SSRI withdrawal symptoms...allow yourself a little time here to get a feel for how the pill is going to work.

I am trying to figure out how to answer the part about overcoming panic taking medications plus therapy, because I think people tend to hand that answer out to depressed and anxious people ("SSRI+CBT is what you need!") when it's actually more subtle than that. There are accommodations you need to give yourself if you have panic. Panic needs a little emotional room. Our usual response is to try to squelch it, push it away, hide from it, and that really doesn't help. Our brains and bodies are trying to tell us something during panic, and even though what they're telling us is wrong (i.e., you're not dying, having a heart attack, going to throw up in front of people, going insane, whatever), trying to shut them up isn't helpful, and I think sometimes the process of CBT is a little bit like trying to shut the voice up. I mean, not exactly, but it is an attempt to reason with a part of your brain that is making the most logical assumptions on earth (here's something deadly, let's get away!), and while I know that people do find comfort in that mode of therapy, I always want to remember the notion that it might not be the best approach for everyone--mostly so that people don't feel guilty if it doesn't work (as it didn't for me, which made me worry that I was either too crazy or too stupid for it to work...or too lazy, or lacked insight, or whatever).

It's not the easiest point to explain, and I'm certainly not doing a good job of it, but panic isn't like a broken leg, right? You can't slap a cast on it and have done with it. It is a series of responses, and habits based on those responses, and emotions built up around those habits, and this is complex enough that it can make the SSRI+CBT combo feel like something plucked off a flowchart rather than something that is geared toward your personal subtleties and experiences, and when the first treatment mode doesn't work, it can lead to some worry and dismay over why you're not reacting like everyone else out there.

Before I confuse things further, let me skip straight to the moral of the story: Do give CBT a try in combination with your med. Do give the med time to work. Do keep in touch with your doc, as frequently as you need to, about progress. But give yourself room to react as an individual. Don't worry too much if your experience doesn't match the common experiences, timelines, and advice you see around. I mean, if they do, great! But always give yourself room. Panic is tricky, and it's not easy to learn to live with, but it can be done.
posted by mittens at 11:45 AM on December 10, 2013 [3 favorites]

You really should talk to a therapist as soon as you can, they can help you evaluate whether CBT is something you should start now. Another approach to consider is mindfulness meditation, which was very helpful for me in dealing with panic attacks. You need to slow your brain down when it starts going into overdrive, and getting a feel for the flow of your thought will help you do that.
posted by InfidelZombie at 11:48 AM on December 10, 2013 [1 favorite]

I'm a little concerned that the new GP prescribed the Celexa to you without setting up an appointment for a follow-up visit in the first place. Whenever you are ealng with drugs which can affect your mental state, let alone is designed to do so, like an SSRI or anti-anxiety med, you really should be monitored. A scheduled follow-up at four to six weeks, when those drugs should have had time to start working, is pretty much the bare minimum as far as monitoring goes.

That's one reason why if you have mental health issues that require medication it is often best to work with a psychiatrist, who will understand if you have a rough first month and can help you figure out whether to up, stop, or continue taking a particular med. Mine encourages me to call any time I feel like something's not working the way it should (and will fit me into his schedule immediately if I'm in crisis).

My advice to you is to go back to the GP for a follow-up within the next week or two at the latest. If the GP can't fit you in within the next two weeks, ask for a referral to a psychiatrist when you call the GP's office. Otherwise, you can probably get a referral when you go in, and I think you should pursue this, as a psychiatrist can also help with suggestions and coping mechanisms. He/she will work with you and for you in a way that your GP can't (both because of their different medical training and because busy GP's only allot about 15 minutes to each patient on a good day).
posted by misha at 12:04 PM on December 10, 2013

Speaking as someone who has recovered from agoraphobia (as well as approximately 10 other phobias) the time to get CBT is RIGHT NOW.

In my own case, my situation was severe enough that I did not leave the house one time for 6 weeks. I had EXTREME anxiety. I did conventional therapy, anxiety medications, ameliorating behaviors. Nothing really did much. I did CBT and within a month 90% of my attacks were gone, Within a year 98%, within 2 years basically done. Mind you, at my peak I was having 20+ attacks a DAY. Seriously. I really feel like taking advice from people who have not personally recovered from them is of limited benefit. They are trying to help, but they just can not know what you are up against.

Get CBT right now. (And do NOT let some therapist BS you into doing something else).

Check back with us in a month. You likely will have a new lease on life.

Feel free to memail me if I can be of any further benefit. I believe you can and will be free of this.
posted by jcworth at 12:17 PM on December 10, 2013 [1 favorite]

I agree with a lot of other posters. CBT + Celexa = much, much happier and higher functioning version of myself. I struggled with general anxiety and did CBT for several years without an SSRI. When I finally started on Celexa and was still going to CBT, things vastly improved.

It isn't uncommon to have a lot of the symptoms you're having in the first 10 days on Celexa or any SSRI. I started on 10mg and was nauseous and stressed out for about the first month, but it all evened out. I upped it to 15mg after about a year and had the same symptoms come back for a few weeks, but now it's fine again.
posted by anotheraccount at 2:53 PM on December 10, 2013

SSRIs can certainly make people feel worse for the first few weeks to a month, before they start to feel better. It's not at all uncommon as you seem to already be aware, and yes this is why it's normal to start at a very low dose. Citalopram can take over a month to start working properly, though it sometimes kicks in faster too. I am not a doctor; all of this is my personal understanding based on my own experience with SSRIs, conversations with doctors, and my own informal research over the years.

Typically a new patient will start on a "tolerance" dose (which some cursory research suggests is in fact 20mg for citalopram, though it's also common to do the first week at 10mg and then step up to 20mg) something which is probably too low to have therapeutic effect but which will hopefully show up any nasty side effects without making them too nasty. Patients who are new to SSRIs have an increased risk of suicide among other things, so this is a serious concern. It sounds like your doctor is pursuing this course with you, though it also sounds like there's an even more cautious course that he could try. As an aside, watch out for weight gain; not everybody gets weight gain on SSRIs (and not everybody who gets weight gain on one SSRI gets it on all of them) but it can definitely happen. I've been trying to get rid of these 20 pounds of Paxil fat for years now.

Now, there's a good chance that you'll even out after a month or so and find that your medication begins helping you significantly. (The success rate for citalopram is roughly 65%, pretty high for an antidepressant.) You don't necessarily need to give up on it, unless the detrimental effects are unbearable or your doctor thinks that you should. (If you do stop, whatever you do don't go cold turkey – SSRI withdrawal is awful, and you need to carefully step down your dosage under the supervision of a doctor if you want to avoid it, which you do.) You should talk to your doctor about your reaction, if for no other reason than to make a medical professional aware that you're having this reaction in the first place. You and your doctor could also talk about lowering your dosage for a while before stepping back up to 20mg, or about switching to a different SSRI or a different class of antidepressant that you might tolerate better.

I take escitalopram, which as others have mentioned is very similar to the citalopram that you're taking right now. One of the reasons I chose it is that I'd heard (and my doctor agreed) that it tends to have a somewhat lower side-effect profile than other SSRIs. In my case that turned out to be true – I get a moderate beneficial effect which is very helpful to me, and experience no side effects at all. I got lucky; not everyone has such a good outcome, it's very idiosyncratic. However it's entirely possible that your doctor will know of an SSRI that tends to work well for people who have a bad time with citalopram. Maybe that's escitalopram, or maybe it's something else. Maybe he'll add a benzodiazepene anxiolytic to your prescription as a short-term, as-needed control for the anxiety while your body acclimates to the citalopram (I don't know if this is something that doctors often do, it's just something that came into my head).

Anyway, talk to your doctor (I hope he's a good one). Depression is poorly-understood, the mechanism of action for SSRIs is poorly-understood, and reactions are complex and vary a lot from person to person. There's a lot of good information out there and this thread is a good starting point (I also highly recommend the straight-talking crazymeds.org as a great patient-centric resource) but the only real way to chart an informed course of action is through repeated conversations with your doctor. Good luck, and feel better.
posted by Scientist at 3:03 PM on December 10, 2013 [1 favorite]

I think you should stick with it a little longer unless the side effects are truley overwhelming. If you do not feel an improvement at the one month mark for any SSRI or SNRI, do not waste anymore time in switching medications.

SSRI withdrawal is worse for some than for others. However, in my humble opinion it is a little overstated. Again I understand that everyone is different but I if you stop you medication after one month or two months you may feel some discomfort but it will almost certainly not be traumatically awful. Stepping down is always good, but I have stopped cold turkey on several SSRIs with only very minor symptoms. I have always felt worse starting than stopping an SSRI.

Onto medication options: SSRIs can obliterate anxiety for some, but usually require a signifcantly higher dose to work for anxiety than they do for depression. 100mg of Zoloft killed my severe somatic anxiety issues, but also left me with a very flat affect (basically emotionless), which is why I stopped.

You may already know this, but there are other good options as well. Some tricyclics like mirtazapine or even imipramine work are more effective for some people and don't have as bad sexual side effects, but may have more severe side effects in general. Clonidine is great for physical anxiety at bedtime, and also a great sleeping aid (has personally been a lifesaver for me). I am a huge proponent of Lyrica, (this is what finally cured my anxiety issues). It is only approved in the EU for anxiety and not yet in the US, so it is prescribed off label. Many psychiatrists have not yet prescribed this for anxiety so they will not bring it up. I had to bring it up and actually ask for the medication, but my psychiatrist agreed to try it and surprise surprise after trying about 20 different drugs this was the best option for me.

So in conclusion 1) Stick in there, the process can be a guessing game and take a while. Do not give up. My thoughts and empathy are with you. 2) If you think a certain med might work for you for whatever reason, do not be afraid to discuss it with you physician.
posted by WhitenoisE at 3:17 PM on December 10, 2013 [1 favorite]