Signs, Symptoms, & Long-Term Effects of Cymbalta (Duloxetine) Addiction

Cymbalta is the brand-name version of duloxetine, which is a “dual-inhibitor” SNRI-type antidepressant. It is most commonly prescribed to treat depression and anxiety, although it is also used to treat some forms of pain such as diabetic neuropathic pain and fibromyalgia.

Article at a Glance:  

Cymbalta is a SNRI antidepressant used to treat depression and anxiety.  

The dosage of Cymbalta is typically 60 mg daily, up to 120 mg per day. 

Side effects of Cymbalta include nausea, dry mouth, and constipation.  

Cymbalta is not addictive when taken properly, although withdrawal symptoms can occur.  

Long-term effects of Cymbalta may include appetite changes and weight gain. 

Cymbalta is the brand-name version of duloxetine, which is a “dual-inhibitor” SNRI-type antidepressant. It is most commonly prescribed to treat depression and anxiety, although it is also used to treat some forms of pain such as diabetic neuropathic pain and fibromyalgia. As of 2014, Cymbalta was the seventh most commonly prescribed drug in the United States.

Cymbalta is usually taken in 60mg daily doses, but it can go up to 120mg in some cases. While abuse of this substance is rare, there have been recorded overdoses from 1000mg of Cymbalta. Most of the time, overdoses are caused by taking duloxetine at the same time as alcohol or other depressants. An overdose of duloxetine can involve

• Extreme sleepiness
• Vomiting
• Coma
• Blood pressure that is too high or too low
• Fainting
• Seizures

Generally, duloxetine is not addictive, as it does not produce a noticeable rush or high. However, like many addictive substances, it can cause withdrawal symptoms when treatment is stopped. For this reason, patients should stop taking Cymbalta under the supervision of their doctor, slowly reducing the dose and monitoring withdrawal symptoms.

Cymbalta has also been linked to serotonin syndrome, a dangerous condition that occurs when too much serotonin accumulates in the body. Serotonin syndrome can cause hallucinations, seizures and unconsciousness; it can be fatal if left untreated. As a result, patients taking duloxetine should be on the lookout for unusual side effects such as agitation, rapid heart rate, shivering and muscle rigidity.

Duloxetine is a medication typically used to treat depression and anxiety disorders. SNRIs work by increasing serotonin and norepinephrine in the body, as opposed to the more popular SSRIs (such as Prozac and Zoloft) that affect only serotonin levels.

Duloxetine is taken orally once or twice a day. It begins working within two weeks and is usually taken for a minimum of six months. It may take longer for some people to start experiencing a benefit from taking the drug, and the length of the treatment will vary widely. Many people take it for several years.

Common side effects of Cymbalta include

• Nausea
• Dry Mouth
• Constipation
• Loss of appetite
• Fatigue
• Increased sweating
• Dizziness and lightheadedness, particularly when starting a course or following an increase in dosage

Other, less common side effects include sexual dysfunction, liver damage and colitis. Liver damage is more likely if you mix alcohol with duloxetine, which is one of the reasons why it is not recommended to drink alcohol while taking the drug.

As a rule, duloxetine is not an addictive substance when taken correctly. However, many people experience negative withdrawal symptoms, also known as “discontinuation syndrome,” which can include increased anxiety, mood swings, dizziness, nausea, confusion, and difficulty sleeping. Some patients have also reported feeling suicidal during their withdrawal. For the most part, these symptoms go away within a couple of weeks, although for some people it takes two to three months for the medication to leave the system fully and for withdrawal symptoms to disappear.

In a study carried out by Cymbalta’s manufacturer, in which patients were unknowingly switched from duloxetine to a placebo, 44 percent of test subjects developed discontinuation syndrome, with ten percent having severe symptoms. Another study showed that people who had taken the medication for a long period of time were more likely to develop discontinuation syndrome, with 60 percent of people who had taken it for two years or more being affected.

To prevent these withdrawal symptoms, a course of Cymbalta is usually stopped gradually, with patients reducing their doses slowly over several weeks. This limits the negative side effects of withdrawal and allows the patient to remain stable during the process. You should never stop taking duloxetine suddenly or without your doctor’s approval. Doing so could damage the progress you have made by taking it.

Many people take duloxetine for long stretches of time to manage pain, major depressive disorders and generalized anxiety disorders. While loss of appetite and subsequent weight loss are common symptoms of Cymbalta, some long-term users have reported weight gain after prolonged usage of the drug. For the most part, though, the drug has no lasting negative long-term effects when taken correctly and under the supervision of a doctor.

The most important thing to remember is this: do not to stop taking duloxetine suddenly because you feel you are fine, or because you feel it is no longer helping you, as this can make things worse.

For more information about Cymbalta, other antidepressants or another substance, please contact The Recovery Village. Our staff are here to answer any questions you may have.

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The Recovery Village aims to improve the quality of life for people struggling with substance use or mental health disorder with fact-based content about the nature of behavioral health conditions, treatment options and their related outcomes. We publish material that is researched, cited, edited and reviewed by licensed medical professionals. The information we provide is not intended to be a substitute for professional medical advice, diagnosis or treatment. It should not be used in place of the advice of your physician or other qualified healthcare providers.

Risks of Long-Term Effects of Cymbalta on the Entire Body

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High-Risk Adverse Effects of Cymbalta

Cymbalta use is also associated with several high-risk effects that impact your ability to live a normal life. Worse, several of these effects may pose a significant danger to your life. When experiencing these concerning effects, it is crucial to seek medical attention immediately:

• Eye pain
• Vision changes
• Seizures
• Vomiting
• Black or bloody stool
• Liver failure
• Bleeding events
• Orthostatic hypertension
• Suicidal thoughts or behaviors

High-risk effects for Cymbalta occur every day in the US. Research has found that short-term Cymbalta effects are generally found to continue and intensify after long-term Cymbalta use. Chronic and life-threatening adverse reactions include liver failure, which can increase with alcohol use. 

Other serious effects include the increased risk of bleeding events. This could result in gums that bleed more easily, frequent nose bleeds, gastrointestinal bleeding, or other types of uncontrolled bleeding. These events can be hazardous and even life-threatening depending on the circumstances.

Cymbalta use can also result in orthostatic hypertension, which is a condition characterized by a sudden drop in blood pressure, often while standing or getting up from a sleeping position. This can result in dizziness which could cause a person to pass out. The risk of experiencing this effect increases when using medication for high blood pressure.

Serotonin Syndrome

Long-term effects of Cymbalta on the brain vary, but many pose a serious risk to your health. As mentioned, Cymbalta blocks the normal function of the brain, impacting levels of important neurotransmitters. 

One such condition caused by Cymbalta, though rare, is serotonin syndrome, which occurs when the drug forces the body to build up abnormally high levels of serotonin.⁵

Serotonin syndrome can cause dangerous changes in blood pressure and heart rate, loss of muscle control, and even seizures. Serotonin syndrome can occur when you start a new serotonergic medication or increase the dosage of one that is currently taken.   

The risk of developing this syndrome increases with the use of other serotonergic medications concurrently, which can result in poisonous levels of serotonin being activated. Serotonin syndrome is also referred to as serotonin toxicity and the condition can be fatal. Symptoms of serotonin syndrome include:

• Fast heartbeat
• Muscle rigidity
• Hallucinations
• Coma
• Tremor
• Spontaneous convulsions, spasms
• Confusion, disorientation
• Severe dizziness
• Fever over 100 degrees F or 38 degrees C
• Severe nausea or vomiting

Overdose Risks

Due to its laundry list of potentially dangerous effects on brain chemistry, Cymbalta use demands the careful guidance of an experienced medical professional who understands the various complications associated with prescribing this drug as an antidepressant. Unfortunately, Cymbalta overdoses can occur and are a severe risk to your health. The risk of overdose increases with alcohol and other CNS depressants.

Overdosing can cause:

• Extreme sleepiness
• Vomiting
• Blood pressure dropping or rising
• Fainting
• Seizures
• Coma

With all these potential risks, Cymbalta may not be ideal for either short-term or long-term use for many individuals. Worse, drug dependence can develop resulting in Cymbalta long-term effects that persist. When you stop Cymbalta use either suddenly or gradually without strategies in place, you are at risk for discontinuation syndrome, a set of symptoms that emerge after dependence has developed. 

Long-Term Effects of Cymbalta and Withdrawal

One of the most serious complications associated with long-term Cymbalta use is the risk of discontinuation symptoms after the last Cymbalta dose leaves the body.⁶ Also referred to as discontinuation syndrome, these are serious and can be life-threatening. Cymbalta comes with a Black Box Warning,⁷ one of the most serious medicine label warnings the FDA can impose. It indicates that this drug can cause withdrawals, suicidal thoughts, and suicidal behaviors. Suicidality is especially prominent when Cymbalta is prescribed to teenagers and young adults.

For these reasons, users of Cymbalta are warned to never stop taking the medication without following a proper tapering schedule with the guidance of a medical professional who is familiar with the process. Both short-term and long-term effects of stopping Cymbalta can be severe. Individuals wishing to stop taking Cymbalta should consult with a qualified physician as soon as possible to begin a gradual taper to zero.

If a person tries to stop Cymbalta without the help of a professional, any conditions they may have been experiencing can reappear and worsen. Re-emerging symptoms may include:

• Dizziness
• Confusion
• Mood swings
• Headaches
• Changes to sleep cycles
• Tiredness
• Increased thoughts of suicide
• clinical worsening

Similar symptoms — as well as new symptoms — can emerge as a direct result of stopping Cymbalta. Discontinuation syndrome occurs in most users who try to quit after long-term Cymbalta use, and the symptoms can be intense. Cymbalta withdrawal symptoms include:

• Seizures
• Suicidal thoughts
• Dizziness, nausea, or vomiting
• Irritability
• Nightmares
• Panic attacks
• Brain fog
• Muscles aches
• Sexual dysfunction
• Headaches

Users of Cymbalta can experience these symptoms over the course of weeks or even months and may linger even after Cymbalta use is completely stopped.⁸ These discomforts can persist regardless of how long it takes for Cymbalta to physically leave the system. The CNS and the entire body will need to correct neurotransmitter dysfunction, nutritional deficiencies and imbalances, and get back to normal for these symptoms to abate. Again, if you decide to stop using Cymbalta, begin a gradual reduction for safety. 

Understanding Long-Term Effects of Cymbalta Use

Medications impact everyone differently. The list of long-term effects of Cymbalta continues to grow as more users report the ill effects they’ve experienced over time.⁹

Antidepressant drug addiction, though rare, is on the rise according to research that is ongoing on the topic.¹⁰ A person can develop a dependency on the way Cymbalta makes them feel. This dependency can also lead to the development of severe negative effects as well as potentially life-threatening cessation symptoms if a person tries to quit using Cymbalta too abruptly, and without proper guidance.

Much data on the long-term effects of Cymbalta and other antidepressants is derived from studies on rats, guinea pigs, and other animals, where 21 days is considered “long-term”. Research published in the International Journal of Risk and Safety in Medicine shows that on careful study, neither SSRIs nor SNRIs actually provided benefits over long-term use (months or years) to patients. The long-term effects of antidepressants are severely under-studied and rarely reported in the medical literature. The FDA lists many potential long-term effects on the package label and advises the medication to be discontinued if these emerge. Patients with cardio concerns should steer away from drugs such as SSRIs and SNRIs that may affect the heart adversely.^12-15

Cymbalta long-term effects can include:

• Addiction
• Dependence
• Seizures
• Suicidal thoughts or behaviors
• Mania, hypomania
• Jaundice
• Liver failure
• Abnormal bleeding, especially when NSAIDs or aspirin are taken concurrently
• Severe renal impairment
• Urinary hesitation, and retention
• Hyponatremia (low sodium levels in the blood)
• Severe weight gain
• Cardiotoxicity issues: tachycardia, QT prolongation, blood pressure issues
• Brain fog
• Agitation
• Fatigue
• Low sex drive
• Constipation
• Diarrhea

While Cymbalta is advertised to help those dealing with severe depression, anxiety, or pain, its list of serious and life-threatening adverse effects may drastically outweigh any actual benefit.

Seeking Alternative Options to Cymbalta

Dealing with serious symptoms of depression or anxiety can be difficult. For individuals struggling with these conditions, typically a patient is advised that prescription medication is the best option for treatment. However, medications like Cymbalta have proven to be potentially dangerous and even life-threatening due to their wide range of adverse reactions. The risk of harm may continue even after deciding to stop using the medication. Cymbalta should be tapered extremely slowly with the help of a professional. When you’re considering taking a prescription medication to address symptoms of depression or anxiety, it is important to consider the risks. You might be surprised how little is still known about medications like Cymbalta.

Researchers study how SNRI drugs manipulate neurotransmitters but it is not known what the long-lasting effects of artificially altering the brain truly are. Pharmaceutical companies have promoted the ongoing theory that antidepressants can correct neurotransmitter deficiencies but have sold the theory as fact. The truth is that there is a lot more to be discovered about what antidepressants truly do to your brain and body.¹⁶

Fortunately, you may not need prescription medication to experience relief from your symptoms. There are several accepted non-pharmacological methods that can address depression and anxiety, and perhaps as well as, or more effectively than SNRIs. Clinically proven effective alternative therapies include correcting the diet, cleansing neurotoxins from the body, acupuncture, music and art therapy, physical exercise, life coaching, talk therapy, and stress-reduction techniques.

Similarly, rehabilitating the gut microbiome, and supplementing your diet with herbal remedies may help you find results like those you hoped to find with drug-based therapy, but without the long-term effects of Cymbalta and similar pharmaceuticals. ¹¹

Avoid the Negative Long-term Effects of Cymbalta

Serious repercussions may impact an individual’s health, as a result of the long-term effects Cymbalta is associated with.

Want to see how ATMC can help? Check out this Cymbalta Withdrawal Success Story to see how we helped Becky withdraw from Cymbalta so she could feel like herself again.

what you need to know – Drink-Drink

Please note that some men and women in this study reported improvements in sex drive, performance and satisfaction with Cymbalta treatment. This may be because the medication helped reduce the symptoms of their condition. As a result, their sexual health may also have improved.

Some side effects of Cymbalta may affect your health in the long term, but this is not common.

For example, liver failure is a rare but serious side effect of Cymbalta. Alcohol abuse can increase the risk of liver failure. The liver damage that develops due to this side effect does not disappear after you stop taking Cymbalta.

You may be wondering if it is safe to take Cymbalta for a long time. Studies have verified the safety of the drug for up to 6 months. A 2009 study found Cymbalta to be safe when taken for 12 months. Your doctor can talk to you about his understanding of the long-term use of Cymbalta.

It is a good idea to discuss all your medications with your doctor from time to time. Together you can discuss your condition and decide whether you should continue taking Cymbalta for a long time.

Continue reading for answers to some frequently asked questions about the side effects of Cymbalta.

How long do the side effects of Cymbalta last?

The duration of side effects of Cymbalta may vary. Some of the more common side effects, such as drowsiness, dizziness, and decreased appetite, are usually temporary. These side effects usually subside within a few days or weeks of starting treatment.

Common side effects may get worse after your doctor increases the dosage, but this is usually temporary.

Other side effects are more likely to continue as long as you are taking the drug. Examples include increased sweating and sexual side effects. These side effects are usually not serious.

The side effects of Cymbalta can affect each person differently. For example, in some people, nausea may be a mild, temporary side effect. For others, it can be annoying. In studies, a small percentage of people had to stop taking the drug because of nausea.

If you experience any unpleasant side effects, you should not suddenly stop taking Cymbalta. It’s best to talk to your doctor first. If you and your doctor decide that you should stop taking the drug, they will advise you on the best way to do so.

Do older people have a higher risk of side effects from Cymbalta?

No, that doesn’t seem to be the case. In general, older people (aged 65 and over) have a higher risk of drug side effects than younger people. But in Cymbalta’s studies, older people had the same side effects as younger people.

Can Cymbalta cause weight gain?

Cymbalta does not usually cause weight gain. Studies have not reported weight gain as a side effect.

In fact weight loss is more likely than weight gain with Cymbalta. This is due to the fact that the drug usually causes a decrease in appetite and nausea.

These side effects can lead to weight loss, especially in children. For this reason, if your child is taking Cymbalta, their doctor will monitor your child’s weight and height during Cymbalta treatment.

If you have questions about weight gain while taking Cymbalta, talk to your doctor.

Will the side effects of Cymbalta vary depending on the dose I use (20mg, 30mg or 60mg)?

Some side effects of Cymbalta may be dose dependent. Cymbalta comes in the following dosages: 20 milligrams (mg), 30 mg, and 60 mg. A higher drug strength may be accompanied by a higher risk of certain side effects.

Common dose-dependent side effects of Cymbalta include nausea, fatigue (lack of energy), constipation, dizziness, decreased appetite, and increased sweating.

Side effects explained

Find out more about some of the side effects Cymbalta may cause.

Sweating more than usual

Sweating more than usual is a common side effect of Cymbalta. This side effect may increase with higher doses of the drug. In addition, hot flashes (also called flushes) are a possible side effect of this medication.

Some people may only notice excessive sweating in certain situations, such as during strenuous activity or in humid weather. Others may have increased sweating more frequently, including when trying to sleep.

What can help

Increased sweating is not a harmful side effect, but it can be uncomfortable. Here are some tips that can help alleviate this side effect:

• Use a strong deodorant.
• Shower more often.
• Wear lightweight fabrics
• Use a ventilator at night.

If this side effect continues to bother you, your doctor may suggest you change your dosage or switch to another drug.

But if Cymbalta is especially effective for your condition, you may not want to switch to another drug. In this case, your doctor may suggest treatment for your sweating. Examples of drugs sometimes used to treat this side effect include:

• benztropine (cogentin)
• cyproheptadine
• terazosin

with your doctor.

eye problems

Eye problems aren’t a common side effect of Cymbalta. But this drug may increase the risk of serious eye problems, such as glaucoma (a buildup of pressure within the eye).

Cymbalta may cause pupil dilation in humans. This can cause serious vision problems, including loss of vision, especially in people with angle-closure glaucoma. Symptoms may include:

• sudden changes in vision
• eye pain
• eye redness
• swelling in or around the eye

What may help

If you have angle-closure glaucoma, you should not take Cymbalta. If you are not sure if you have this disease, consider visiting an ophthalmologist. The results of an eye exam can help you and your doctor decide if it is safe for you to take Cymbalta.

If you experience any of the above symptoms while taking Cymbalta, you should contact your doctor. Urgent treatment is needed to prevent permanent vision loss.

If you have questions about eye problems that Cymbalta can cause, talk to your doctor.

Liver damage

Although rare, Cymbalta can cause serious liver damage that can be fatal. The risk of this side effect may be higher with alcohol. It may also be higher in people who already had liver problems before starting Cymbalta.

The following may indicate that there’s a problem with your liver:

• pain in the upper right part of your abdomen (belly)
• itching
• dark urine
• yellowing of the skin or whites of the eyes
• elevated liver enzymes

What can help

To prevent this side effect, talk to with your doctor about any liver problems you have. It is also important to be honest about your drinking. Talk to your doctor about whether you have had liver problems or alcohol use in the past.

If you develop any of the above symptoms, get emergency medical care right away.

Sleep problems

Insomnia (trouble falling or staying asleep) may occur while taking Cymbalta. In studies, this side effect was reported more frequently in people taking the drug for long-term musculoskeletal pain. (This is pain in the bones, muscles, tendons, ligaments and nerves.)

Insomnia is also a common side effect in children taking Cymbalta.

What can help

Here are some tips that can help improve your sleep:

• Try to exercise regularly.
• Avoid caffeine after dinner.
• Practice good sleep hygiene.

If you experience insomnia after starting Cymbalta, talk to your doctor. They may suggest temporary use of sleeping pills such as melatonin. Or they may adjust your dosage or discuss other treatment options with you.

Suicidal behavior and thoughts

Simbalta has a warning box for suicidal behavior and thoughts. The boxed warning is the most serious warning from the Food and Drug Administration (FDA). It warns doctors and patients about drug side effects that can be dangerous.

Antidepressants such as Cymbalta may increase the risk of suicidal behavior and thoughts in children and young people 24 years of age and younger. This is a rare side effect. Studies show that the risk increases after a person first starts treatment or increases the dose.

What can help

While taking Cymbalta, you should watch for any new behaviors, feelings, or thoughts. This is especially important in the first few weeks after starting Cymbalta or after a dose adjustment.

Consider using a journal or app to take notes about your mood. You can ask your loved ones to let you know if they notice you are behaving differently. Tell your doctor right away if you or someone else notices any change in your behavior or mood.

Suicide Prevention

If you think someone is at immediate risk of harming themselves or harming another:

• Call 911 or your local emergency number.
• Stay with the person until help arrives.
• Remove all weapons, knives, medicines, and other items that could cause harm.
• Listen, but don’t judge, argue, threaten or yell.

If you or someone you know is thinking about suicide, get help from a crisis or suicide prevention hotline. Call the National Suicide Prevention Hotline at 800-273-8255.

Allergic reaction

Like most medicines, Cymbalta may cause an allergic reaction in some people. But this side effect was not reported in studies.

Symptoms may be mild or severe and may include:

• skin rash
• itching
• redness (temporary warmth, redness, or increased skin color)
• swelling under the skin, usually on the eyelids, lips, hands, or feet
• swelling of the mouth, tongue, or throat that causes difficulty breathing

What can help

If you have mild symptoms of an allergic reaction, such as a mild rash, call your doctor right away. To manage your symptoms, they may suggest an over-the-counter antihistamine you take by mouth, such as Benadryl (diphenhydramine). Or they may recommend a product you apply to your skin, such as a hydrocortisone cream.

If your doctor confirms that you have had a mild allergic reaction to Cymbalta, they will decide whether you should continue using it.

If you have symptoms of a severe allergic reaction, such as swelling or difficulty breathing, call 911 or your local emergency number right away. These symptoms can be life threatening and require immediate medical attention.

If your doctor confirms that you have had a serious allergic reaction to Cymbalta, he may ask you to switch to another treatment.

Tracking side effects

Consider keeping a record of any side effects you experience during your treatment with Cymbalta. You can then share this information with your doctor. This is especially helpful when you first start taking new medications or using a combination of treatments.

Your side effect notes may include things like:

• what dose of the drug you were taking when you had the side effect
• How soon after starting this dose did you experience a side effect
• What were your symptoms due to the side effect
• How did it affect your daily activities
• What other medications did you also take
• Any other information you think important

Taking notes and sharing them with your doctor will help him learn more about how Cymbalta affects you. Your doctor may use this information to adjust your treatment plan if necessary.

Warnings for Cymbalta

Cymbalta has several warnings that may affect whether you can safely use this drug to treat your condition.

Boxed Warning for Suicidal Behavior and Thoughts

Cymbalta has a boxed warning for suicidal behavior and thoughts. The boxed warning is the most serious warning from the Food and Drug Administration (FDA).

Antidepressants such as Cymbalta may increase the risk of suicidal behavior and thoughts in children and young people 24 years of age and younger. After launching Cymbalta, you should be on the lookout for any new behaviors, feelings, or thoughts. Tell your doctor right away if you or your loved ones notice any changes in your behavior or mood.

See “Explanation of Side Effects” above for more information.

Other warnings

Cymbalta may not be right for you if you have certain medical conditions or other health conditions. Talk to your doctor about your medical history before taking Cymbalta. The list below includes factors to consider.

Liver or kidney problems. The liver and kidneys help clear Cymbalta from the body. In a person who has liver or kidney problems, Cymbalta levels could become too high in their body. This can worsen the drug’s side effects. In rare cases, Cymbalta may cause liver failure. People who already have liver problems may be at higher risk for this side effect. Before taking Cymbalta, tell your doctor about any liver or kidney problems you have.

Angle-closure glaucoma. Cymbalta may cause pupillary dilation, which may aggravate some vision problems. If you have angle-closure glaucoma, taking Cymbalta may cause you to lose your vision. Talk to your doctor about other treatment options.

Heart or blood pressure condition. Cymbalta may increase your blood pressure. If you already have high blood pressure or heart problems, taking Cymbalta could worsen your condition. Before starting this drug, tell your doctor about any heart or blood pressure problems you may have.

Slow gastric emptying. Cymbalta capsules are delayed release. As such, they have a special coating that helps protect the medicine from stomach acid. If you have a medical condition that can slow gastric emptying, such as diabetes, the special coating may be broken. This may make Cymbalta less effective in treating your condition. Before taking Cymbalta, talk to your doctor about any medical conditions you have.

Diabetes. If you have diabetes, Cymbalta may make it difficult to control your blood sugar. Before taking Cymbalta, talk to your doctor about a blood sugar management plan.

Seizures. Cymbalta may increase the risk of seizures. But the drug has not been studied in people with epilepsy (a seizure disorder). If you have a seizure disorder, your doctor may suggest another treatment option for your condition.

Bipolar disorder or mania. Cymbalta may cause or worsen certain symptoms of bipolar disorder or mania. If you have bipolar disorder or mania, talk to your doctor about the risks of taking Cymbalta. If you are not sure if you have any medical conditions, your doctor may test you for them before you start taking Cymbalta.

Low sodium. Cymbalta may cause low sodium levels. If you have problems with sodium levels, talk to your doctor before taking Cymbalta.

Bleeding problems. Cymbalta may increase the risk of bruising or bleeding. If you have a medical condition that causes bleeding problems, taking this drug may make your condition worse. Tell your doctor about any current or past bleeding problems before you start taking Cymbalta.

Allergic reaction. If you’ve had an allergic reaction to Cymbalta or any of its ingredients, you shouldn’t take Cymbalta. Ask your doctor what other medications are better options for you.

Drinking alcohol and Cymbalta

Drinking alcohol is not recommended while taking Cymbalta, especially in large quantities.

Alcohol can make some of the common side effects of Cymbalta worse, such as:

• nausea
• drowsiness
• dizziness liver and liver failure. It can be life threatening.

  If you drink alcohol, talk to your doctor about whether it is safe for you while taking Cymbalta. You can also ask them how much alcohol is safe for you.

  Pregnancy and lactation while taking Cymbalta

  The use of Cymbalta is not recommended during pregnancy because its effects are not fully known. The drug may harm the developing fetus.

  If you’re pregnant or you’re considering a pregnancy, talk with your doctor. They’ll tell you about treatment options that may be safer during this time.

  Cymbalta passes into breast milk and the drug may affect a child who is breastfeeding. Drowsiness and feeding problems have been reported in breastfed children while taking Cymbalta.

  If you are breastfeeding or planning to breastfeed, talk to your doctor. They can help you weigh the pros and cons of breastfeeding while taking this drug.

  What to ask your doctor

  Many people find that Cymbalta is an effective treatment for their condition. When you’re considering Cymbalta as a treatment option, it’s a good idea to talk to your doctor about the risk of side effects. Here are some questions you can ask:

  • Do my medical conditions increase the risk of side effects when taking Cymbalta?
  • Are there other ways to help me manage side effects from Cymbalta?
  • Can I make any lifestyle changes that will help reduce my need for Cymbalta in the future?

  For tips on managing your mental health and personal stories, you can subscribe to Drink-Drink newsletters about anxiety and depression.

  Ask a pharmacist

  Q:

  My child has generalized anxiety disorder and their doctor suggested treatment with Cymbalta. I’m concerned about the drug’s suicide warning. How common or rare is this side effect, and how can I avoid it?

  Patient Anonymous

  A:

  The risk of suicidal behavior and thoughts when using Cymbalta is rare. But Cymbalta has a warning about this side effect. The boxed warning is the most serious warning from the Food and Drug Administration (FDA).

  Compared to placebo (treatment without an active drug), antidepressants such as Cymbalta have been associated with increased suicidal behavior and thoughts. This risk has affected children and young people aged 24 and younger.

  For more information about this FDA boxed warning, see “Explanation of Side Effects” above.

  If your child’s doctor prescribes Cymbalta, be sure to monitor your child for any changes in behavior or mood. This is especially important when treatment with Cymbalta is started or the dosage is changed. Contact your child’s doctor immediately if you notice any changes in your child’s behavior or mood.

  Melissa Badowski, PharmD, MPH, FCCP Answers represent the views of our medical experts. All content is for informational purposes only and should not be considered medical advice.

  Registration data: Drink-Drink has made every effort to ensure that all information is accurate, complete and up to date. However, this article should not be used as a substitute for the knowledge and experience of a licensed healthcare professional. You should always check with your doctor or other healthcare professional before taking any medication. The drug information contained herein is subject to change and is not intended to cover all possible uses, directions, precautions, warnings, drug interactions, allergic reactions, or side effects. The absence of warnings or other information for a given medicinal product does not mean that the drug or combination of drugs is safe, effective, or suitable for all patients or for all specific uses.

  Articles of the Psychiatry Clinic in Moscow read on the website of the SCH Clinic

  The aim of this project was to provide a coherent and evidence-based approach to the pharmacotherapy of post-traumatic stress disorder (PTSD). It has been found that selective serotonin reuptake inhibitors (SSRIs) and norepinephrine (SNRIs) are not as effective as previously thought. Moreover, there has recently been increased awareness of the long-term side effects of antidepressants. New evidence suggests that eliminating fragmented sleep and nightmares may improve symptoms that are often seen in PTSD. At this initial stage, special attention is paid to prazosin and trazodone; if PTSD symptoms persist, an antidepressant may be tried. For psychosis associated with PTSD, an antipsychotic may be added. In resistant cases, two or three antidepressants can be used sequentially. After this, or with partial improvement and residual symptoms, augmentation can be tried; the best options are antipsychotics, clonidine, topiramate, and lamotrigine.

  Algorithm for the treatment of post-traumatic stress disorder
  (download in pdf and admire)

  After confirming the diagnosis, specify the presence of concomitant factors:

  Substance use disorders substance abuse. Before starting treatment, you should find out if the patient is using psychoactive substances.
  Patients with PTSD have an increased risk of prescription drug abuse. Do not prescribe benzodiazepines.
  This algorithm does not apply to patients who actively use psychoactive substances. Ideally, the patient should remain sober for at least a week before starting treatment.

  Bipolar disorder

  Patients with bipolar disorder have an approximately 2-fold increased risk of PTSD.
  SSRIs and other antidepressants may destabilize the patient.
  Treat nightmares and awakenings with prazosin. If possible, refrain from prescribing antidepressants.

  Psychosis

  Psychotic symptoms in patients with PTSD may be part of PTSD or may be indicative of a comorbid psychotic disorder.
  Skip item (2). If primary psychosis is present, treat it first with an antipsychotic.

  Depression

  A history of depression increases the risk of developing PTSD, and PTSD increases the risk of depression. This association may be explained by dysregulation of the hypothalamic-pituitary-adrenal axis.
  Response to antidepressants may be impaired in patients with PTSD and concomitant depression.
  Children/adolescents with PTSD show greater variability in response to antidepressants than those diagnosed with depression alone.
  Treat psychotic depression with an antidepressant and an antipsychotic.

  Dissociation

  Dissociation is associated with more traumatic events and more severe PTSD.
  With dissociation, response to pharmacotherapy is less predictable.
  Psychotherapy may be recommended as a first-line treatment for dissociative symptoms of PTSD.

  Anxiety

  Many patients with PTSD complain of anxiety. Doctors may diagnose a comorbid anxiety disorder, such as generalized anxiety disorder, social anxiety disorder, or panic disorder. The appointment of drugs with proven efficacy in the treatment of these disorders is recommended.
  Often more detailed examination reveals that anxiety is actually a consequence of PTSD. Triggers for anxiety symptoms can be events that are similar to or reminiscent of the patient’s traumatic experiences.
  PTSD patients are often treated with benzodiazepines, hydroxyzine, gabapentin, and buspirone, which have been prescribed to treat anxiety. But if the symptoms are caused by PTSD, these drugs are useless: none of them have an evidence base to support their effectiveness in PTSD.

  Pregnancy

  Physiological changes during pregnancy (eg decreased protein binding of the drug, increased hepatic metabolism and renal clearance, delayed gastric emptying) may affect blood levels of the drug.
  Drugs with a teratogenic risk should be avoided during the first trimester, especially from weeks 3 to 9.
  Paroxetine is the only SSRI with a teratogenic risk category D in the US (“There is evidence of risk to the fetus based on clinical trial data”). Do not prescribe paroxetine.
  Valproic acid has pronounced teratogenic effects. Do not prescribe valproic acid.

  Smoking

  Bupropion has been shown to help people with PTSD quit smoking.

  (2) Do you have sleep problems?

  A growing body of evidence indicates that sleep disturbance is a major symptom of PTSD and a major source of distress and dysfunction in PTSD patients. Therefore, sleep problems should be assessed at the very beginning of treatment and again after each stage of treatment.

  In many patients, sleep problems can worsen the main daytime symptoms of PTSD (excessive psychophysiological activation, avoidance, re-experiencing of traumatic events). Another argument for addressing sleep problems first is the availability of prazosin, a drug that targets sleep disturbances in PTSD patients and works better than drugs considered effective for the overall symptom profile of PTSD (SSRIs and SNRIs).

  Sleep disorders in PTSD:

  excessive psychophysiological activation associated with difficulty falling asleep and maintaining sleep;
  trauma-related nightmares;
  awakenings without nightmare memories;
  increased sleep latency.

  Increased noradrenergic activity is believed to underlie problems with falling asleep and maintaining sleep in PTSD. SSRIs can sometimes make these symptoms worse.

  Sleep disturbances in PTSD may be associated with sleep apnea, restless leg syndrome, periodic limb movements during sleep, problems with sleep hygiene, nicotine withdrawal, and medical problems associated with sleep fragmentation (eg, pain and nocturia).

  Often used to treat symptoms of sleep deprivation secondary to PTSD and other causes of insomnia, caffeine is sometimes a major contributor to insomnia.

  (2a) Patient has nightmares

  Prazosin:

  For nightmares, prazosin, an alpha1-adrenergic receptor blocker, is recommended as the first-line drug treatment for hypertension and symptoms of benign prostatic hyperplasia.
  Prazosin has been shown to be effective for trauma-related nightmares, general sleep quality and, to some extent, general symptoms of PTSD in military and civilian trauma patients.
  The risk of hypotension due to prazosin is minimized by slowly increasing the dose over several weeks.
  Currently available evidence for the efficacy of prazosin is limited. However, prazosin can be recommended as a first line treatment for nightmares and related sleep disorders.
  Consideration should be given to the importance of sleep disturbances in PTSD and the central role sleep problems may play in this disorder. Added to this are the medical risks associated with sleep problems. Finally, prazosin’s acceptable side effect profile makes it more attractive than SSRIs.
  Prazosin is recommended not only for patients with nightmares, but also for patients with insomnia, awakenings without nightmare memories, and nightmares during sleep.
  Prazosin is often used at reduced doses resulting in negative results. It is recommended to use the dosage used in the largest positive trial of prazosin (Raskind MA, Peterson K, Williams T, et al. A trial of prazosin for combat trauma PTSD with nightmares in active-duty soldiers returned from Iraq and Afghanistan. Am J Psychiatry 2013;170:1003–10).
  Dosing protocol complicated. Effective management of the patient and elimination of side effects requires time and a series of outpatient visits. If the patient is already taking one or more antihypertensive drugs, the addition of prazosin may cause dizziness or lower blood pressure. It is recommended that therapy be discussed with the physician prescribing the antihypertensive drug.

  Dosing protocol for men

  bedtime medication:
  1 mg x 2 nights

  2 mg x 5 nights

  4 mg x 7 nights

  6 mg x 7 nights

  10 mg x 7 nights

  15 mg x 7 nights

  maximum 20 mg at bedtime
  daily dose (around 10 am to avoid overlapping with night dose; use mobile phone to set reminder):
  Week 2: 1 mg

  Weeks 3-4: 2 mg

  Weeks 5-6: 5 mg

  Dosing protocol for women

  Women need lower doses for reasons that were not fully explained by the study authors.

  bedtime medication:
  1 mg x 2 nights

  2 mg x 12 nights

  4 mg x 7 nights

  6 mg x 7 nights

  maximum 10 mg at bedtime
  daily dose :
  Weeks 2-3 : 1 mg

  Weeks 4-5: 2 mg

  It may be necessary to slow down or change the dose increase depending on side effects.
  Do not prescribe this protocol and expect the patient to follow it exactly without further consultation. It is recommended to meet with the patient every week or two.
  To get the most out of prazosin, it is very important to start therapy by discussing expectations. A person who has nightmares every night and sleeps 3 hours a night will not go to no nightmares and 7-8 hours of restful, restorative sleep in a week or two. The process will be gradual and may take weeks or months as the dose is slowly increased and depending on tolerance.
  Night terrors worsen in some patients after the first few doses, although this may be due to accidental traumatic triggers rather than drug effect. The patient must be prepared for this and strongly advised to continue treatment and (if well tolerated) to move to higher doses, after which this problem usually disappears.
  The first sign of real improvement may be that the nightmares become less severe or the time it takes to recover from them and return to sleep decreases. Thereafter, the frequency of nightmares should decrease, although disturbing awakenings without recollection of nightmares may continue even after patients forget the nightmares. The dose of prazosin should still be increased as indicated in the protocol, trying to achieve complete absence of nightmares, disturbing awakenings, and an increase in total sleep time.
  Some patients may require a dose higher than indicated in the protocol. In the scientific literature, there are reports of cases where patients have safely increased the dose to 30 and even 45 mg.
  Other alpha1-adrenergic blockers such as doxazosin and terazosin may have similar effects on PTSD symptoms. Although these drugs do not appear to cross the blood-brain barrier, researchers speculate that a decrease in peripheral adrenergic activity, including tachycardia, may attenuate psychophysiological arousal.
  If sleep has improved to an acceptable level, the patient may continue to take prazosin.

  Trazodone:

  If prazosin does not relieve insomnia or nightmares but does not resolve problems with falling asleep, then low dose trazodone can be given. It can be added or completely switched to it, depending on how the effect of prazosin is evaluated.
  The sedative antidepressant trazodone has been shown to be effective for sleep disorders in patients with PTSD. Side effects include excessive sedation, dizziness, orthostatic hypotension, syncope, priapism in men. Moderate stimulation of erection is more common; before the advent of drugs such as sildenafil, trazodone was recommended for patients with erectile dysfunction.
  Trazodone is sometimes referred to as the “ideal sleep aid”. It has a triple sleep-promoting effect (5-HT2A, alpha-1, and H1 receptors), a short half-life, and a low risk of addiction.
  Side effects should be closely monitored when using trazodone. Since priapism can be caused by other drugs, including prazosin and phosphodiesterase inhibitors (eg, sildenafil), the combination of trazodone with these drugs requires special care. The combination of trazodone and prazosin can also lead to blood pressure problems.

  (2b) Trouble falling asleep

  If the patient has difficulty falling asleep, but does not complain of nightmares and excessive psychophysiological activation, trazodone is recommended.
  Since prazosin is generally not sedative, it may be less useful in this situation.
  In early treatment, trazodone may work well enough to obviate the need for further pharmacotherapy in a patient with difficulty falling asleep. However, the evidence for its effectiveness in these circumstances is far less strong than the evidence for prazosin’s benefit in the treatment of nightmares.
  Trazodone may also be a good option for patients who need a short-term sleep fix while waiting for medications (eg, SSRIs) to relieve general symptoms of PTSD to start working.
  Trazodone is effective for SSRI-induced insomnia and nightmares. If at any subsequent steps in the algorithm with SSRIs and SNRIs, insomnia/nightmares persist or return after improvement, trazodone should be added.

  Other drugs for insomnia:

  If prazosin and trazodone are ineffective or poorly tolerated in steps (2), (2a) and (2b), other drugs with hypnotic properties that are often used in clinical practice can be used. However, there is no strong evidence to support their use in early treatment.
  There is evidence of benefit of imipramine and amitriptyline in PTSD. However, their side effects, especially at high doses, are associated with anticholinergic, cardiac, and seizure risks. TCAs are undesirable if the patient is suicidal (overdose can be deadly).
  Doxepin has been investigated as a treatment for primary insomnia at very low doses of 1-6 mg. It has been found to be safe and effective for transient or chronic insomnia. In the United States, doxepin was approved as a hypnotic in 2010. Its mechanism of action appears to be related to its effect on the histamine h2 receptor. Doxepin has no advantage over sedating antihistamines such as diphenhydramine or hydroxyzine. A rapidly developing tolerance to the sedative effects of antihistamines precludes their long-term use, which is usually needed in PTSD.
  Physicians often use benzodiazepines to treat sleep disorders in PTSD. There is a high risk of abuse when using benzodiazepines in PTSD patients who have had substance problems. As with the use of antidepressants for bipolar disorder, practice for the use of benzodiazepines for PTSD (with or without comorbid substance abuse) differs significantly from clinical guidelines. In both cases, doctors see improvement in the short term, without noticing the placebo effect and not foreseeing the potential harm in the long term. Benzodiazepines may be given if there is a history of good response without abuse. If the patient has a history of substance abuse, a small amount may be given to test the patient’s ability to use drugs appropriately.
  Esopiclone, a GABA-A/benzodiazepine receptor agonist, has been shown to be effective in treating insomnia associated with PTSD.
  Quetiapine is widely used to treat sleep disorders in PTSD. However, a review of reports of the use of quetiapine to improve sleep in various patient groups leads to the conclusion that in this case, the benefits do not justify the risks. Quetiapine is not recommended as a first line treatment for insomnia. Weight gain with quetiapine is not dose dependent and can occur even at low doses. There is evidence to support the addition of quetiapine to SSRI therapy after the latter has failed.
  Other hypnotics (eg, zolpidem) and other sedatives (eg, gabapentin) are occasionally used in clinical practice for PTSD-related sleep problems, but the evidence base for them is too low to be included in this algorithm as options in start of treatment.

  (3) Has the patient been treated with SSRIs?

  If the patient does not have significant sleep disturbances, or if prazosin and trazodone were poorly tolerated or only partially effective for residual PTSD symptoms such as increased psychophysiological arousal, re-experiencing traumatic events, and avoidance, then the next step in the algorithm is to prescribe an SSRI.
  One of the reasons why SSRIs do not come first in this algorithm for patients with severe insomnia is the weakness of the evidence base.
  Large reviews and meta-analyses point to weakly proven efficacy of SSRIs in PTSD: 2009 Cochrane review, 2008 US Academy of Sciences Institute of Medicine review, 2005 UK National Institutes of Health and Clinical Excellence meta-analysis.
  In addition, SSRIs are often do not treat insomnia associated with PTSD, but exacerbate it, and besides, they can cause sexual dysfunction.
  In the US, sertraline and paroxetine are approved for the treatment of PTSD. Paroxetine has the best evidence for efficacy, but is more likely than other SSRIs to cause sexual dysfunction, constipation, sedation, drug interactions, withdrawal, and weight gain. The teratogenic risk makes its use problematic during the treatment of women of childbearing potential.
  Evidence supporting the benefits of sertraline is weaker but has fewer side effects than paroxetine.
  Use of citalopram would be prudent. Its efficacy in anxiety disorders and depression suggests that its benefit in treating PTSD may be comparable to that of other SSRIs.
  According to most sources, an adequate course of treatment with SSRIs for PTSD lasts 4 to 6 weeks, although up to 12 weeks is sometimes required.
  Some patients have a partial response to SSRIs or a response limited to individual symptoms of PTSD. Patients who provide a partial response should continue treatment until the increase in benefit reaches a plateau. If improvement does not occur within two or three weeks, increase the dose or switch to another option – see point (4). Augmentation – points (3a) and (5a) – is indicated when the doctor and patient are convinced that the partial improvement was not a placebo effect and is not associated with other aspects of treatment, such as psychotherapy. Before proceeding with augmentation, be aware that SSRIs are far less effective than placebo in controlled trials than is commonly assumed. “Augmentation” of the placebo effect by another drug should be avoided. In addition, augmentation is associated with the risk of increasing side effects and drug interactions, weakening compliance due to the complexity of treatment regimens, and increasing the cost of treatment.

  Alternatives to SSRIs:

  Options that may be considered under (3) include bupropion, mirtazapine, and antipsychotics.
  Nefazodone has few sexual side effects and evidence of efficacy in PTSD, but due to the risk of liver toxicity, it is not considered early.
  Venlafaxine is effective for PTSD but has sexual side effects and is best used as a second line option.
  Bupropion performs better in younger patients and in those who received monotherapy rather than bupropion augmentation.
  There is stronger evidence for mirtazapine, although its use is limited by the risk of weight gain.
  Another alternative to SSRIs in item (3) is antipsychotics. As noted in the comments to point (2), some clinicians prescribe quetiapine as first-line monotherapy, although there is very little evidence to support this practice. Since the risks of side effects are significant, quetiapine is not suitable for early treatment.

  (3a) Patient has psychosis associated with PTSD

  Psychotic symptoms are common in patients with PTSD. Symptoms include phenomena related to the initial trauma, such as the screams of soldiers, visual hallucinations of the enemy, or other themes related to the combat. Delusions unrelated to the trauma may also occur. Delusions associated with PTSD are not bizarre, are not associated with thought disorganization, flattened or inappropriate affect, and are not associated with substance abuse or withdrawal. Delusions don’t just occur during dissociative flashbacks.
  Patients with psychotic symptoms can be identified as a separate subgroup of patients with PTSD who are recommended for early augmentation. The atypical antipsychotics are the drugs of choice for this purpose.
  An antipsychotic is recommended to be added when the patient is not responding satisfactorily to the antidepressant and is also experiencing PTSD-related psychosis.
  The evidence base supports risperidone.
  Quetiapine is widely used, there is evidence of its effectiveness as an augmentation in non-psychotic PTSD, it can also be used for augmentation in PTSD with psychosis.
  If the patient responds well to the addition of an antipsychotic and the SSRI shows minimal benefit, the SSRI may be phased out to determine if the drug is needed to improve.

  (4) Second stage: SSRI, SNRI, mirtazapine

  If the patient does not have psychosis and has not responded to SSRI therapy in (3), then another SSRI, SNRI (venlafaxine) or another type of dual-acting antidepressant may be given (mirtazapine).
  Previously, venlafaxine was considered to be insufficiently effective in PTSD due to its noradrenergic action, while PTSD is characterized by excessive noradrenergic activity. However, studies have shown that venlafaxine can be considered as a second-line pharmacotherapy option. At the same time, the evidence base does not allow it to be preferred to SSRIs as a first-line agent. It is ineffective in case of excessive psycho-physiological activation and sleep disorders. In addition, venlafaxine’s cardiac safety concerns may be significant in some patients.

  (5) Third stage: SSRIs, SNRIs, mirtazapine, nefazodone

  If two adequate courses of monotherapy with SSRIs, SNRIs or mirtazapine fail to improve, proceed to the third stage.
  Choices now include nefazodone, which is not recommended earlier due to its liver toxicity (fatal hepatotoxicity occurs in about one in 250,000 patients). Overall, the side effect profile of nefazodone makes it a very attractive option—no weight gain or sexual side effects, less sedation than trazodone, and a low risk of priapism.

  (5a) Augmentation (depending on residual symptoms) or other monotherapy

  In case of non-response or partial response, various options are available: mood stabilizers (gabapentin, lamotrigine, levetiracetam, tiagabine, topiramate and valproic acid), antipsychotics (aripiprazole , olanzapine, quetiapine, risperidone, and ziprasidone), antiadrenergics (alpha-1 antagonists, alpha-2 blockers, and beta-blockers), and MAOIs. Evidence for their effectiveness ranges from inconclusive to fairly strong.
  Some of these treatments may be appropriate for all symptoms of PTSD (avoidance, increased psychophysiological activation, reliving traumatic experiences), while others target one or more symptoms.

  The general principle is to minimize polypharmacy by critically evaluating the partial response and determining whether the improvement was due to a real drug effect or non-specific response to other treatments (including psychotherapy) or changed life circumstances (including hospitalization). If any of the latter is suspected, one should switch to another drug rather than adding a new one. However, it should be borne in mind that the totality of manifestations of PTSD includes many symptomatic domains with different reactions to drug treatment, in connection with which some patients are indicated to take several drugs.

  The material was prepared with the support of the Clinic for Emergency Psychiatry sch.