Q:  Back in Control after Reducing Effexor

Dear Dr. Phelps,

I have been on Effexor XR 225 mg. for almost 3 years, along with Klonopin 1 mg. at bedtime.  Back in November I started on Lamictal due to some hypomanic-like behaviors and am now at 200 mg.  About 4 weeks ago, my started getting really angry, most directed towards those I work with.  Brash, brusque, and took anything as a slight against me.  I started getting a little worried and paranoid because I knew my anger was way out of line.  I told my psychiatrist and he said cut the Effexor to 150 mg.  within 20 hours, I am back to my old self.  It was as if someone pulled the plug on this obsessive anger and I feel very calm.  I feel back in control.  But I am afraid this will happen again.  How do I prevent it or try to do damage control? 

Thank you,
Laurie

Dear Laurie -- 
Glad to hear that your psychiatrist took that step, and that your symptoms seemed to respond.  Sounds like she/he is concluding that your symptoms are bipolar-like and that a mood stabilizer like lamotrigine is perhaps a better way to go than to rely on the antidepressant and anti-anxiety agent (Klonopin).  

The simplest, though not necessarily the certain explanation, is to assume -- based on the effect you describe from lowering the antidepressant -- that you are having some hypomanic symptoms elicited by the antidepressant which responded to lowering the Effexor dose.  Therefore many psychiatrists, but not all, would continue to gradually lower your Effexor dose, hoping to reach zero.  See my discussion of this issue and the data we have on this approach on my website on the Antidepressant Controversy page.  

However, of course we can't be certain that you didn't just cycle up there on your own, and that the Effexor had nothing to do with it.  With that view, there would not necessarily be "protection" from lowering the dose further and you could have some depressive symptoms show up instead.  One way to avoid this is to lower the Effexor dose, if you and your psychiatrist decide to do that, very slowly, e.g. taking at least 4 months to get from where you are to zero.  Slower yet might be wise, if things are going well; and as you'll see from that linked page, there's a lot of difference of opinion on this and some psychiatrists would not taper you off at all, they'd leave you on some Effexor. And we don't have clear data to say whether that's a good idea (as some now say; see the "Altshuler" data) or a bad idea (as is the opinion, in most cases, of Dr. Ghaemi of Harvard, whose work you'll also see cited there). 

However, and here comes my opinion now, it seems as though in general one would want to find out whether one medication, in this case lamotrigine, might be sufficient to control your symptoms (and if not, just what symptoms needed to be controlled:  cycling?  hypomania?  depression?).  So even without getting into the "antidepressant controversy", you could justify tapering off the Effexor (slowly) -- if that's what you decide with your psychiatrist. 

Dr. Phelps
 

Published May, 2004