Paroxetine and OSA

[Perrybucsdad]

During my lunch, I stumbled across three articles that made me go Hmmmm. I don't know if this has been talked about before, but I thought it very interesting.

Back in 2000, I suffered a massive brain hemorrhage from a berry aneurysm in my brain (what I lovingly call my "brain fart"). I also was/am on warfarin for blood clotting due to a mechanical heart valve that I have. These were all results of congenital defects. Anyhow, during my recovery from my brain fart (bf), he doctors put me on an SSRI. I forget exactly which SSRI they had me on, but I remember that I didn't tolerate it well, and eventually they took me off. A few years later I had complained to my doctor that I could go from zero to pi$$ed-off on no time (massive type A personality) and suffered from anxiety. He placed me on paxil at that time, and to my relief, I noticed it calmed me down quite a bit, removed a ton of the anxiety and reduced my blood pressure (I think). I also noticed that my libido was significantly affected almost to the point that I no longer want to have sex because nothing will happen.

Anyhow, after reading these three articles, I am starting to wonder about the relationship of psychotropic agents such as paxil and OSA. I don't recall having OSA prior to the SSRI introduction (although I have no way really to confirm this).

I have also run across studies (I wish I could remember where I saw these so I could look at them again, but I will have to look for them) that shows that drugs like SSRI's can cause the muscles on the throat to lose their tone or relax more easily and adds to the problems of OSA.

I think I have also seen statements (possibly on this site, or maybe it was the other Apnea site) that OSA can also cause depression or anxeity, and then doctors place their patients on the SSRI and it becomes a vicious cycle.

Anyhow, I don't know if this is a "what came first, chicken or the egg" problem or if it is even relevant, but it has me thinking. I know I would love to be off the paxil so that my libido would come back, and then I have the "hmmmm" in the back of my head wondering if this could either eliminate or reduce my OSA issues. I also know that you just can't stop an SSRI and I remember when the doctor took me of it the first time almost 10 years ago, I had a hard time withdrawing from it. And even if I could get off of it, would the anxiety come back and rule my world?

So, just wanted to post these three articles and also ask if anyone else here has come across similar information and possible results that may be significant. IN no way does this mean I'm going to run out and stop my APAP and my paxil, but it really has me wondering.


Articles
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2139928/

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2045710/
(If I understand this correctly, 39% of patients referred to this sleep clinic were taking antidepressants prior to referral.)

http://www.annals-general-psychiatry.com/content/4/1/13

- John

[ThirdOutOfFive]

Humm. A bit over my head, but it doesn't surprise me that sleep and mood are interconnected. The hippocampus of the brain is involved in both mood and sleep. Thanks for the links.

[Perrybucsdad]

The hippocampus of the brain is involved in both mood and sleep.

The interesting about what you just said is that the hippocampus was very close to where my brain fart occurred too. More things to make me go Hmmmm.

[Mary Z]

Thanks for posting links to these articles. The last article is particularly interesting. I have been on CPAP therapy for 3 1/2 years. I don't know if I had OSA for any length of time prior to diagnosis. I have been on antidepressants and mood stabilizers since 2005. I have never been able to achieve an AHI under 5 despite repeated titrations and the use of and AUTO machine with systematic changes by myself. My sleep doc is convinced that my medications are the cause of this, but only recently have I also come to that conclusion. It has also been suggested to me by a RPSGT that my depression may be a factor. Interestingly my doc lowered the dose of one of my mood stabilizers by half and I have immediately had a decrease in AHI. Unfortunately it has only been two nights since the improvement and I don't know if it will continue. I hope so. My psych doc never believed that any of my medications would impact my OSA. I think she, like I once did, confuse OSA with respiratory depression. They are not the same thing. I may just not have one without the other as there is not a cure for depression or OSA, only treatment. I did not know there had been any studies about this effect of SSRI's and OSA, but find it interesting and heartening. It has been very hard and confusing to be totally compliant with my therapy and not achieve optimal results. I have also had an improvement in my daytime sleepiness since the reduction in medication although I still take Nuvigil. Lucky for me the med she halved has no withdrawal except perhaps insomnia so I could just stop it without weaning.
Now if I could just get rid of this depression (which has been life long and runs in my family).
As to Paxil, it was one of the hardest drugs I ever discontinued. For weeks after slowly decreasing the dose I would have to break the pill into fourths and take 1/4 when withdrawal set in.
Thanks again. You made my day.

[M.D.Hosehead]

---dad,

JMO, here.

A discussion with your dr. about tapering paroxetine is definitely worth having, considering that:

1. Sexual function is important to the quality of life.
2. XPAP alone may be enough to treat anxiety, irritability, and even blood pressure.
3. If it turns out you need pharmacologic help for the above, there are non-SSRI's that should work as well without undesirable side-effects.

Paroxetine causing OSA is very speculative; I wouldn't count on OSA going away, but if it did---even better.

[Mary Z]

JMO, interesting reply. Correct me if I'm wrong, but I got the impression from the last article that more seratonin may decrease the effects of OSA.
All in all it's just all very interesting to me considering my poor response to CPAP and long history of depression.
I'd sure like to find a psychiatrist who knew more about this and the appropriate treatment for depression (in a person with depression prior to OSA) with comorbid OSA.
If switching to a non SSRI would help my OSA I'd do it in a heartbeat (though the other drugs do have their serious side effects).

[RandyJ]

John,

Several years ago I took an SSRI for a year or so (Lexapro) and had no difficulty getting off of it; I cut the dosage in half over a 2 week period, then that dose in half for another week, then stopped. No problems.

It's true that once your brain has to make serotonin on its own, it may take a little bit for it to kick in. Some people say that they don't feel as energetic or as "up" as they did when taking the SSRI. But many make the transition seamlessly, as I did.

I personally don't want to take any medications daily that aren't absolutely essential to my health. If you have your doubts about the Paxil, talk to your doctor and work out a plan to wean yourself off. You can always go back on if being without it is too tough.

[Perrybucsdad]

Randy, Paxil is a tough one to kick because the half life of the medication is so short, so it depletes very quickly. I do know that at times they will switch people from Paxil to some other one (name escapes me, but it is a major antidepressant, but I don't know if it has anti-anxiety for my case).

A very cool thing about my CPAP treatment was that the first doctor that I met with was a sleep disorder doc, but his main training was in psychiatry... I always thought it was odd, but when I asked him about it, he told me that many people who have OSA are depressed because of a host of different things that OSA does to oneself. He may be a great dr for me to follow-up with and ask him how I can try and titrate off the paxil. I'm scared to do it as I don't miss the anxiety that I once had. I would get anxious about everything (bills, kids, wife, pets, house, bills, work, bills, bills, etc)... lol. I would love to get off it though and reclaim some of my life... and if I had to stay on CPAP, well, that's not so bad.

Mary, I'm encouraged with your story about the AHI coming down and maybe that also gives some credence to all this. With working at a hospital, I have free reign over all the journals that we have electronically, so I will be doing some more research to see what else I might find. I know me getting my sex drive back would make my wife's day. Being that she and I are in our 40's, she is in her prime and I just am not interested ever (or tired, etc).

- John

[Paper_Nanny]

I also noticed that my libido was significantly affected almost to the point that I no longer want to have sex because nothing will happen.

If it were me, I would consider that an intolerable side effect and would be asking to try a different medication in the hopes of finding something that worked for me and did not produce intolerable side effects.

Deborah

[Paper_Nanny]

Correct me if I'm wrong, but I got the impression from the last article that more seratonin may decrease the effects of OSA.

That was my understanding also-- Both depression and OSA are linked to a low level of seratonin. Increasing seratonin could result in an improvement of both conditions.

Deborah

[Muse-Inc]

Might investigate taking omega 3 essential fatty acids 'cause they increase serotonin levels without the side effects associated with prescription SSRIs...well, maybe not true if you're allergic to fish , in which case, you'd have to take Neurotonin, algae-based EFAs. Interesting studies out there. You can take an SSRI as well as large amts of omega 3s without experiencing too much of a serotonin boost -- pubmed abstracts maybe? The fish oils will support serotonin levels as you taper off the SSRI if that's your choice...as always, discuss with your doc beforehand.

[Perrybucsdad]

Thanks for the info Muse. Isn't there another herbal or some remedy as well that can supplement the serotonin levels? St John's Wart or something like that?

[Mary Z]

5-HTP in doses of 100- 300 mg may increase seratonin levels. I would only attempt this under a doctors care as seratonin syndrome can be potentially fatal, or at least have bad consequences, I had an uncomfortable brush with it after taking a does of Kava with my regular SSRI.
There are SSRI's- the newer ones, Cymbalta and Pristiq which are supposed to have less effect on libido, I don't know their effect on anxiety. A dose of wellbutrin (Wikipedia- Bupropion (/bjuːˈproʊpi.ɒn/ bew-proh-pee-on;[1] marketed as Wellbutrin, Zyban, Voxra, Budeprion, or Aplenzin; and formerly known as amfebutamone[2]) is an atypical antidepressant and smoking cessation aid. The drug is a non-tricyclic antidepressant and differs from most commonly prescribed antidepressants such as SSRIs, as its primary pharmacological action is thought to be norepinephrine-dopamine reuptake inhibition. It binds selectively to the dopamine transporter, but its behavioural effects have often been attributed to its inhibition of norepinephrine reuptake.[3][4] It also acts as a nicotinic acetylcholine receptor antagonist.[5][6] Bupropion belongs to the chemical class of aminoketones and is similar in structure to stimulants cathinone and diethylpropion, and to phenethylamines in general.) is some times used to counteract the effects Of SSRI's on libido.

I have not found it to be effective, but perhaps the dose was not large enough.
I have heard of wellbutrin used as a wakefulness agent.
A trial stopping the Paxil, under your doctors care and being alert for return of symptoms, may be a good idea. There are other antianxiety agents that you could try in small doses (valium, xanax, klonopin, etc.).

I am appreciating this brainstorming, finding it very thought provoking. My thoughts at present are that stopping my SSRI might not be a good idea ( I have severe depression), but that weaning off the mood stabilizers, or at least decreasing the dose woud be an interesting experiment. I have not had a manic episode in a while, but that could be because of the mood stabilizers.

I know there is a difference in respiratory depression and hypopneas, but I wonder if respiratory depression may lead to hypopnea. I have never had O2 desats. Does anyone have any thoughts on this? I think my psychiatrist confuses OSA and respiratory depression.

I mentioned this before, but halving my dose of geodon, a mood stabilizer has markedly decreased my daytime sleepiness ( I stopped the morning dose). If I do ok for a while (no return of mania) I may ask about decreasing, or stopping the night time dose. Anything I can do to decrease my AHI would be worth a try.
Again I would appreciate nay thoughts on respiratory depression and hypopnesa.

[Perrybucsdad]

... There are other antianxiety agents that you could try in small doses (valium, xanax, klonopin, etc.).

I would be cautious taking those as I have taken xanax in the past, and it made me a bit spacey. Also,in the third article above, there was this one statement on page four, near the bottom left of the page (in the full PDF) that would concern me regarding using one of these and having OSA...

Clinically, this is of particular concern, as sedative antidepressants and adjunct treatments for depression may actually exacerbate OSA. Notably hypnotics prescribed to treat depression-related insomnia might further decrease the muscle tone in the already functionally impaired upper airway dilatator muscles, blunt the arousal response to hypoxia and hypercapnia as well as increase the arousal threshold for the apneic event, therefore increasing the number and duration of apneas [39,40].

I would rather just be off of them all together if possible. I'll talk with the one doctor who I meet with for my OSA who was also a psychiatrist. He should have some good insight on how to taper off of it.

- John

[Perrybucsdad]

I was able to obtain a very nice text book titled Principles and Practices of Sleep Medicine 5th Edition today. IN it, I ran across some information with regards to SSRI's and sleep disorders. I thought I would post it below for those of you who have been following this thread.

Kryger, MD, FRCPC, M. H. (2011). Principles and practice of sleep medicine. (5 ed., pp. 545-546). St. Louis, MO: Elsevier Saunders.

Selective Serotonin Reuptake Inhibitors
Selective serotonin reuptake inhibitors (SSRIs) selectively and potently inhibit the reuptake of serotonin, but they also exhibit norepinephrine and dopamine reuptake inhibition, muscarinic cholinergic antagonism, inhibition of various cytochrome P-450 enzymes, and other actions. In addition, numerous serotonin receptor subtypes mediate a variety of actions. Individual SSRIs also differ in their effects on serotonin receptor subtypes as well as in their actions at other receptors, which may explain why SSRIs may be associated with both insomnia9,18 and daytime sedation.

Polysomnographic studies of SSRIs generally indicate disruption of sleep continuity and suppression of REM sleep. Fluoxetine, which has been studied most extensively, decreases TST and increases wake time and stage 1 sleep both in normal subjects during single-night studies with doses of 20 to 60 mg21 and in depressed patients with doses of 20 to 80 mg for up to 1 year. Fluoxetine has been associated with prominent slow eye movements in non-REM sleep. SSRIs are also associated with increased frequency of periodic limb movements during sleep, restless legs syndrome, and REM sleep without atonia. Paroxetine (15 to 30 mg) decreases TST and increases awakenings in normal subjects with 1- to 2-day dosing. There also is evidence of increased awakenings and sleep fragmentation after 5 weeks of paroxetine treatment in depressed inpatients. Fluvoxamine has had similar effects on the sleep architecture of depressed patients. Citalopram produced the typical decrease in REM sleep but no changes in sleep latency or TST during 5 weeks of treatment in one study of depressed patients.

SSRIs usually do not negatively affect daytime performance or cognitive functioning and may actually improve functioning in some patients, but data are limited. One placebo-controlled study reported memory impairment with paroxetine but improvement in a verbal task with sertraline. A single nighttime dose of fluvoxamine in healthy subjects showed increased daytime sleep latencies compared with dothiepin but no change compared with placebo in a modified MSLT study.