Original Medium article: My depression and the magic of antidepressants

Updates from Ben Mann Monthly newsletter, edited to always use the generic names:

Dec 2019

• Started taking escitalopram. See Medium post above for details.

Jan 2020

• Switched to sertraline. I felt great on escitalopram, but I found it hard to sleep through the night. In the spirit of science and experimentation, I switched to sertraline a few weeks ago. I've been observing the differences in my own psychology. While it's difficult to put the changes into words, I'd say the adjustment period has been more challenging: bouts of nausea, dizzyness, trouble following conversation. My sleep has improved a little and mood is still great. In another week I'll talk to my psychiatrist and see if I can try one more thing. If I expect to take something every day for years, a few months of experimenting seems worthwhile!

Mar 2020

• Venlafexine and bupropion. As part of my tour of antidepressants, I tried two more. I had blood in my stool every day for the week I was on venlafexine, so I stopped that early. I tried bupropion for about 3 weeks, but it didn't give me the mood effects I got from the SSRIs. I've since switched back to sertraline and will try adding trazodone to help sleep.

Dec 2020

• Life updates. Switched from sertraline to fluoxetine to reduce brain fog 🧠

June 2022

• Followup on my depression post. In January 2020 I posted My depression and the magic of antidepressants. ~3k reads later, when I tell people I'm taking antidepressants, I usually refer them to the story to hear all the details. I've now been taking antidepressants for almost two years. Once I decided I was in it for the long haul, I worked with my psychiatrist to try six different options: tianeptine, escitalopram, venlafexine, sertraline, bupropion, and fluoxetine. I tried each for at least 6 weeks except for venlafaxine, which might have given me bloody diarrhea for two weeks. Each time I hit the 6 week mark, I met with her to discuss how it was going - symptoms, side effects, mood journal stats, etc. When I found something I liked, I tried it for a few months. Sometimes it didn't work well and I was sad for a few weeks. It was worth the short term pain of experimentation. I settled on fluoxetine, which I've been taking for about a year. For me, it has the least brain fog, sleep disruption, sexual effects, dry mouth, and plenty good mood and anxiolytic effects. A few times, I've tried tapering off to see if maybe I don't need it anymore, but I do. Within a week I'm back to how I was before I began experimenting with antidepressants. It's not good. Taking a pill every day and avoiding grapefruit juice is easy and worth it. I've also found that once I mention that I'm on antidepressants, an astounding number of people say, "me, too!" This stuff works, folks. Others tell me they tried an antidepressant many years ago and didn't like it due to side effects, lack of success, or something else. Yep, some of the ones I tried didn't do anything for me. I was lucky that the first one I tried (escitalopram) made me feel great on day 0. Don't give up! Work with your doctor to keep trying. If you find something that works, it'll change your life.

October 2022

• SSRI Experiments. For the last 10 days I have not taken any medication at all. Compared to other times I tried this since starting SSRIs 3 years ago, this time is going much better! Confounding factors: I'm married, have a baby, and am on paternity leave. My sleep improved dramatically after ~48h, and probably as a downstream effect my daytime focus and alertness also increased. Mood has commensurately fallen to ~pre-SSRI levels, but I feel like I'm better able to cope now. This has occasionally led to projection, but I quickly recognized and resolved it. I've started a discussion with my psychiatrist to try either a lower dose of fluoxetine or another class of antidepressants like SNRIs.

Nov 2022

• Life updates. Still off SSRIs, feeling good

Dec 2022

• Started duloxetine. Stopping fluoxetine in late October fixed my sleep, but some of the mood issues returned. I wasn't nearly as depressed as before I started taking SSRIs, and I felt like I had more buffer and tools to handle it when I did feel down. Occasionally I still had an episode. Last week I started taking duloxetine. One night I stayed up until 4am, but otherwise it's been good so far. Let's see how it feels in a month!

Jan 2023

• Duloxetine update. It's been almost 6 weeks since I started taking duloxetine. Euda getting older, changes in my work status and fitness, Diana going back to work, and weather are all big confounders, but I'm feeling pretty great! Sleep is still good, so that solves my complaint with fluoxetine. I'm on a very low dose, but I will probably stay right here since it's working for me. Better living through chemistry ✨🧠

June 2023

• Duloxetine was giving me night sweats. I tried combatting the sweats with benztropine, but it wasn't effective. I took two weeks off everything and sleep improved, but mood deteriorated. Inspired by my low dose of duloxetine, I recently started a half dose (50 mg) of sertraline. Seems better so far! Instead of eventually escalating to 100 mg, let's see if this level is sustainable.
• Wow, looks like overly high doses of antidepressants might be systemic. Of course, later in the same post Scott casts doubt on the study suggesting dosages are too high. But certainly titration is important.
• Turns out there are some specific guidelines on switching between different anti-depressants.
• A friend compiled all my anti-depressant updates! Very helpful for me too. Edited to always use the generic names.
• Good perspective on SSRI's "low effect size" -- they're about as effective as NSAIDs like ibuprofen, which I definitely trust for a headache. They've just gotten a bad rap.

Oct 2023

• Sertraline started messing up my sleep just like it used to, even at half dose. Switched back to duloxetine and started taking glycopyrrolate at half dose, which solves the night sweats without cognitive effects. I've been taking this for a few months now and I think it's the best combo I've found so far. A few days ago I tried doubling my duloxetine dose due to what might be high work stress, or might be internal demons. Jury's out on whether it's better, will see.

Dec 2023

• Aborted double duloxetine dose in Oct due to nausea, but decided to resume on Dec 16. Pushed through this time and feeling good. Night sweats are still at bay thanks to glycopyrrolate half dose. Overall side effects minimal, will stick with this for a while.

Feb 2024

• My dentist pointed out that chronic dry mouth, likely as a side effect of duloxetine and glycopyrrolate, caused my gum recession to worsen. When I asked my psychiatrist about what we could do, she suggested switching to selegiline patches. I wrote up my survey of MAOI literature. Based on that, I've decided to give it a shot. I stopped taking duloxetine on Feb 26, 2024 and will begin phenelzine on Mar 18, 2024. I bought a blood pressure cuff and have started taking readings to establish a baseline. Once I start treatment, I'll monitor particularly closely after consuming foods with high tyramine concentrations like cheese and soy sauce. The latest research seems to suggest that the risk of MAOI/tyramine hypertensive episode risk is overblown, and if you are careful you can test things out by consuming small quantities and using blood pressure cuff to validate.

Apr 7, 2024

• Stopped taking phenelzine Mar 27, 2024 due to consistent low-grade headaches, dry mouth severe enough to make my spit foamy and yellow in the morning, consistently dry and bloodshot eyes, sudden poor mood despite initially feeling good. Didn't have any trouble with blood pressure according to the cuff. It's been about 10 days and the side effects are almost gone.
• Psychiatrist recommended TMS. ACX suggests it works well, but is also a big time commitment that I'm not sure I can handle at the moment.
• Considered bupropion again since I gave up after only 3w last time but looked up the stats and lots of people had dry mouth, increasing with dose.
• Thinking about ketamine again. Prescription + compounding pharmacy seems like a good option to try, or maybe https://mindbloom.com/ 

Hi Dr. Kalra,

It's been about 10 days since I stopped taking the phenelzine and the side effects are pretty much gone. Mood is back to baseline low but I'm managing ok.

I finally got a chance to look into TMS. Seems like it works fairly well but I don't think I can make the time commitment right now. I looked around at other options that wouldn't have dry mouth or negative sleep effects. Ketamine came up as a possibility.

You mentioned a while back that Kaiser won't cover it, but that you'd be willing to write me a prescription. This article https://www.astralcodexten.com/p/peer-review-request-ketamine  describes a potential dosing regimen using a compounding pharmacy with 100mg/ml nose spray, .1 ml/spray, 5 sprays/dose. 6 doses over 3w would be 300mg total + some extra to ramp to the correct dose, so 5ml. These look reputable:

https://valorcompounding.com/ketamine/ - Min price is $75, $5/ml → 15ml

https://www.koshlandpharm.com/ - prices not listed

I feel pretty confident in my ability to administer with a therapist in the room, but I could also use https://mindbloom.com to help figure out the dose & protocol, then proceed on my own + therapist  if you think self-administration is not advised.

What do you think?

Best,

Ben

Apr 28, 2024

• Started Mindbloom's 6-week program

Jun 7, 2024

• I took Mindbloom's 6-week course. After an intake session with an RN or NP, they mail you tablets. You can do the sessions at your own pace, and you can pick a non-credentialed guide that helps you prepare for and then integrate your experiences before and after the session. During the session, there's a menu of themed audio you can select from. There's music-only, 7 minutes of guidance, and fully guided. I tried the latter two options. During the first 7 minutes, you dissolve the tablets in your mouth and let it absorb through your mucous membranes before spitting out the rest. Then you "experience the session" for one hour. The last half-hour, you write in a physical journal. Half way through the course, Mindbloom introduced AI-powered speech to text-based integration and journaling in the app. I found it too overwhelming to interact with a machine in an altered state, so I stuck with paper and pen. Once the journaling is over they say not to drive or operate heavy machinery, but mostly I felt good and able to go about my life normally. Between sessions you talk to your NP again to adjust dose, usually upwards. They offered group-based integration sessions, but I didn't try it.
• I felt like I got a lot out of these sessions. Independent of the medicine, I had time to think deeply about what matters to me, what gives me joy, what my priorities are, and generally to appreciate my life as it is. But I also noticed that it felt much easier for me to break free of the bad habits I'd formed lately, and replace them with new ones, which fits nicely with the theory of ketamine as neuroplasticity-inducing. In the last 6 weeks I've exercised more, eaten better, and generally felt less akrasia than usual. I feel more able to mentally and emotionally take a step back when I'd otherwise be caught in the moment, which is a mental motion that mindfulness meditation deeply roots, but which I haven't been doing for many years.
• I'm grateful to my wife for supporting me by taking care of our daughter solo during these weekly 2-hour sessions. With a young kid it's hard to carve out that amount of time!
• Overall, even if these effects are temporary, I got enough out of the program that I'm confident it was worth the time and money. As soon as I finished, there was an up-sell for 6 or 18 more sessions. I'm going to give it a few weeks to see how long the feeling of agency sticks with me, but I'll probably periodically reengage.

Jun 23, 2024

• Mood went back to low baseline. Sleep has stayed excellent thanks to CPAP, so I decided to give low-dose escitalopram another shot. I started with 2.5mg today.