@Downthelanetheycome 2475 wrote:

I have taken only one SSRI and that was lexapro. The level of agitation was so intense I had to get off of it. Even on a reduced dose I had very high anxiety and agitation as well as insomnia. I have had some relief since starting TRT therapy and changing my thyroid protocol 5 months ago. Unfortunately I still need help. Is there an SSRI that is not as agitating as Lexapro? I have been terrified to try another one due to this experience. Thanks

Agitation depends on the dose (e.g. how strongly it increases serotonin), how quickly the liver gets rid of the medication, whether or not there is optimal iron, a person’s native dopamine signaling level (e.g. their tendency for Parkinson’s syndrome), other genetic factors, and whether or not the SSRI also has an antihistaminic or anticholinergic effects, which may possible self-correct the dopamine-reducing effects of the SSRI. As a result of individual difference in the status of these parameters, patients may have different responses to the same medication.

The biggest determinant is dose. This is why it is important to use as low a dose as possible that avoids reaching a point that causes agitation. Some patients use 1/8th of a 10 mg dose of Lexapro, for example, to avoid agitation.

I like Lexapro in that it is fairly specific in its signaling actions and tends to be low in regard to adverse effects compared to other SSRIs – particularly when it comes to weight gain / obesity. But individual differences occur. Thus other SSRIs should also be considered. Some patients, for example, respond better to Zoloft than Lexapro. Some prefer Paxil or Prozac. Etc.

Once a decision is made to change a particular signal – such as serotonin, dopamine, thyroid, etc. – then there is some trial and error to determine what particular treatment will work best due to individual differences in response. Trends can guide you. But individual response may vary.

Why do you miss your wife?

SSRIs generally do not have a period of agitation in the beginning. If agitation occurs, it is an abnormal response. Usually this means there are other problems in the system which predisposes the person to agitation when an SSRI is added. For example, if a person has suboptimal iron, such a person may be more susceptible to agitation or akathisia on an SSRI – depending on the dose.

The key is “suboptimal”. When doing lab testing, a level can be “within normal range” but can still be suboptimal and can thus represent a problem. For example, from my point of view, Vitamin B12 is suboptimal right in the middle of the range. This is because neuron demyelination starts right in the middle of the range. One can even say that B12 is deficient when its level is in the middle of the range. Laboratory ranges can be fairly arbitrary – e.g. set so that some people will fall out of range, rather than set to determine if one is ill or not. Thus, when interpreting lab tests, it is important to correlate the level with the physiologic meaning of the test, rather than simply stating a a lab test is “normal” since it falls within the range.