Serotonin Syndrome: Less Is More

She was nearly thirty, dark haired and round-faced and ambitious, and wanted to be a drug and alcohol counselor, maybe.  Maybe not.  She had only three months of sobriety from alcohol; probably wanted to be one of those people in power.  So many programs dry people out and let them “stay on” a bit.  So many people use their own exaggerated stories to “help” other people stay sober.  A closet industry of subjective touchy feely, trampling, as many do on my long years of difficult, mind boggling training with cheap feel-good.

Her drug and alcohol counselor had told her that she would feel rotten for a while, so she had accepted that. But she felt obligated to tell me that she had felt rotten, so I let her talk and tried to listen.

People coming off alcohol may take as much as a year to get their sleep cycle back (alcohol represses Rapid Eye Movement sleep) and to stop feeling a little bit nervous.  But this was not that.

“Horrible”  (her words) digestive problems, including a constipation that had addicted her to the strongest laxatives available.  Muscle stiffness.  Muscle stiffness???

She was on high doses of both Effexor* (venlafaxine) and Lexapro* (escitalopram).  The doctor from whom I had inherited the patient had been a blithering idiot and should have been beaten to a pulp. Her vital signs were pretty good, thank heaven.

I concluded she had a low grade serotonin syndrome. When too many drugs are given at the same time that do the same thing, all kinds of toxicity and poisoning become possible. People can die from this. The death of Libby Zion is described in the above article. If my patient hadn’t died yet, and she hadn’t, I thought we could get her off at least one of the drugs and do fine.  There were an incredible amount of hurdles to doing this.

She had been suicidal in the past and was afraid of getting back to that place.  We gave her every crisis number in the county.

She asked me how come the other doctor had now known about this.  I had never met the other doctor, and had no idea, and that is the worst question anyone could ask me. I told her what I thought had happened. People sometimes try to do a “cross taper” of serotonin active drugs, removing one while increasing the other. The doctor had left in the middle of the process and seemed to have over estimated the doses. I never found any decent substantiation for this way of doing things in the literature.  I can never, ever get inside the brains of other doctors and explain why they do what they do, because I am not them.

Was there a withdrawal syndrome from either of these drugs?  You betcha.  Of course the drug companies insist on the fact that people don’t die from it, but feelings of transient confusion and electrical shocks and weird sensations had been the alleged cause of an auto accident in another patient.

I wanted to see her once a week.  I told her I did not think she would die, but people had died from this. And I made her confirm contraception.  She needed a pregnancy in the middle of this like a turtle needed a seat belt.

Now came my surprise.  Transportation was too expensive and took too much time out of her college schedule and she did not want to come once a week, in this public mental health system where that was a real sacrifice for me.

Two weeks or three or whatever.  She liked the Effexor*  better than the Lexapro* and there were no problems with early cutbacks.  She started getting some withdrawal symptoms; nerves and feeling “ballistic,” that she felt were affecting her grades.  She looked good, vitals were fine. I did something radical.  I let her stay on a quarter of a 10 mg. pill of Lexapro until after finals.  I suppose she could have it forever if she wanted it.  She was happy, and clinically she was not depressed.

The only problem was–the pharmacist.  I gave her tiny bits of Lexapro* and she had a pill cutter and took her 2.5 mg. a day and was perfectly fine in her life and doing well in school.  I wrote her for tiny amounts of Lexapro* with vague directions of “take as directed” so I did not have to explain to the pharmacy assistant with questionable understanding of the names of pills and none of their contents, or even to one of the fatherly pharmacist owners who sometimes flirts with me, and says “gee, Dr. G., you sure are original.”  I try to minimize their getting between me and my patient.

Last I knew she was still blessing my name and amazed that “less is more, ” which is not a bad message for addicts.  She promised me that when she becomes a drug and alcohol counselor, she will make sure people talk better to their psycho-pharmacologists. They will still need one who reads at least some of the literature, and who cares.