Cymbalta/Duloxetine and hyperoxic mixes...Ox Tox

[Easdem]

Hi!

I've been a diver for over two decades, 12 years as a dive pro, and several years as a cave/tech diver and instructor. I lost my father a couple of months ago (tough times), and I needed a little help to cope with all the emotional stuff that comes with a loss like that.

I started therapy, and the MD prescribed Duloxetine 60mg daily after titrating up. I have no side effects from the medication, and I dive several times a week.

I've looked for research on whether there are higher risks for OxTox/CNS tox on hyperoxic mixes on deco, but I could not find anything.

I don't plan on staying on this treatment permanently, but I have some deco dives planned this year. Any advice?

 

[Duke Dive Medicine]

Hi!

I've been a diver for over two decades, 12 years as a dive pro, and several years as a cave/tech diver and instructor. I lost my father a couple of months ago (tough times), and I needed a little help to cope with all the emotional stuff that comes with a loss like that.

I started therapy, and the MD prescribed Duloxetine 60mg daily after titrating up. I have no side effects from the medication, and I dive several times a week.

I've looked for research on whether there are higher risks for OxTox/CNS tox on hyperoxic mixes on deco, but I could not find anything.

I don't plan on staying on this treatment permanently, but I have some deco dives planned this year. Any advice?

I'm so sorry for the loss of your Dad.

Here's an article from Diving and Hyperbaric Medicine that discusses your question. The recommended depth limitation might give you cause to look further; if so, you're also welcome to make an appointment in the clinic for evaluation.

Best regards,
DDM

 

[Easdem]

I'm so sorry for the loss of your Dad.

Here's an article from Diving and Hyperbaric Medicine that discusses your question. The recommended depth limitation might give you cause to look further; if so, you're also welcome to make an appointment in the clinic for evaluation.

Best regards,
DDM

Thank you...

I find the 20M depth limit interesting as they cite "to minimize the risk of DCI and the slight theoretical risk of worsening inert gas narcosis." At the same time, a higher ATA will affect the potential for inert gas narcosis; I don't understand why it would minimize the risk of DCS- being close to the no-stop limit at 15M is no less provocative than being close to the limit at 40M.

I have been seen at Duke Dive Medicine Clinic before (years ago). Please let me know how to set up an appointment.

Thanks!

 

[kinoons]

It’s an interesting set of recommendations linked to by DDM. I see this as another case of experts taking a best guess with virtually no evidence to back up those guesses. I will acknowledge this fact is stated in their recommendations.

It is also very apparent they are erring on the side of caution. From their own recommendations.

Divemasters and recreational diving instructors with psychiatric issues are in principle unsuited to carrying out diving instruction, but may be deemed suitable for personal recreational sports diving activities based on the current guidelines.​

That’s a pretty strong statement and can be used to preclude well treated patients from their livelihood.

The authors consider the possibility of DCS worsened by the risk of bleeding associated with SSRI use. This is based on case studies and observational data, which cannot establish a causal link between SSRIs and bleeding.

From an analysis in 2022

Langerkranser et al.. performed a meta-analysis looking at medications and spinal hematomas and reported one patient on SSRIs of 160 cases.29 Based on the current literature, three studies have found that SSRIs are not associated with increase bleeding and/or increased perioperative risk, while others have demonstrated that SSRIs are associated with an increased risk in perioperative use.30–34 Auerbach et al. found that there is an increased risk with perioperative SSRI use; however, they did not account for NSAID use.33 The other study that deemed a risk associated with perioperative SSRI use also noted that those patients receiving SSRIs are also more likely to have obesity and cardiovascular disease, which also affect perioperative risks.

Selective Serotonin Reuptake Inhibitors and Associated Bleeding Risks: A Narrative and Clinical Review

Major Depressive Disorder (MDD) is a major cause of disability worldwide and is associated with serious lasting impairment. A leading hypothesis of the pathophysiology of MDD is the monoamine deficiency hypothesis which suggests that depression is caused ...

www.ncbi.nlm.nih.gov

this analysis concludes that more research into the bleeding risk of a SSRI is needed.

Given that somewhere around 13% of the population is on an antidepressant it would be a fair guess that perhaps 1 in 10 divers are taking an SSRI.

Also given the low rate of DCI, I think you’d have to have a huge sample size to get the power high enough to demonstrate the affect an SSRI has on any risk associated with diving, which means by definition the risk is very low.

The recommendations also address nitrogen narcosis. While this concern is also backed up by plausible theory, if a medication alters your perception, the addition of another factor that can alter your perception carries additional risk, there is again no real evidence to back this up. Again considering the widespread use of antidepressants, I would postulate that the absolute risk is very low.

I cannot see the need for a stronger recommendation beyond the standard anytime you start a new medication be aware of how it affects you. If you’re having side affects that would limit your ability to dive safely, then don’t dive. But if you feel well, you’re likely safe to dive as normal.

 

[Duke Dive Medicine]

It’s an interesting set of recommendations linked to by DDM. I see this as another case of experts taking a best guess with virtually no evidence to back up those guesses. I will acknowledge this fact is stated in their recommendations.

It is also very apparent they are erring on the side of caution. From their own recommendations.


That’s a pretty strong statement and can be used to preclude well treated patients from their livelihood.

The authors consider the possibility of DCS worsened by the risk of bleeding associated with SSRI use. This is based on case studies and observational data, which cannot establish a causal link between SSRIs and bleeding.

From an analysis in 2022

Selective Serotonin Reuptake Inhibitors and Associated Bleeding Risks: A Narrative and Clinical Review

Major Depressive Disorder (MDD) is a major cause of disability worldwide and is associated with serious lasting impairment. A leading hypothesis of the pathophysiology of MDD is the monoamine deficiency hypothesis which suggests that depression is caused ...

www.ncbi.nlm.nih.gov

this analysis concludes that more research into the bleeding risk of a SSRI is needed.

Given that somewhere around 13% of the population is on an antidepressant it would be a fair guess that perhaps 1 in 10 divers are taking an SSRI.

Also given the low rate of DCI, I think you’d have to have a huge sample size to get the power high enough to demonstrate the affect an SSRI has on any risk associated with diving, which means by definition the risk is very low.

The recommendations also address nitrogen narcosis. While this concern is also backed up by plausible theory, if a medication alters your perception, the addition of another factor that can alter your perception carries additional risk, there is again no real evidence to back this up. Again considering the widespread use of antidepressants, I would postulate that the absolute risk is very low.

I cannot see the need for a stronger recommendation beyond the standard anytime you start a new medication be aware of how it affects you. If you’re having side affects that would limit your ability to dive safely, then don’t dive. But if you feel well, you’re likely safe to dive as normal.

These are great callouts. I often wonder what the actual frequency of use of different meds is in the diving population. And, I too disagree with the blanket statement about instructors and DMs. Why can't someone who has well-managed depression or anxiety and is safe to dive, teach other divers?

Best regards,
DDM

 

[justinthedeeps]

What physiological mechanism is proposed to produce side effects that affect diving physiology in these cases?

Certain receptors being fiddled with that have specific other measurable physiological effects?

Or do we need to dive into paywalled journal articles for that info?

 

[Duke Dive Medicine]

What physiological mechanism is proposed to produce side effects that affect diving physiology in these cases?

Certain receptors being fiddled with that have specific other measurable physiological effects?

Or do we need to dive into paywalled journal articles for that info?

Duloxetine is a selective seratonin and norepinephrine receptor inhibitor. The package insert says that the exact mechanism of its therapeutic actions is unknown.

Was the article I linked behind a pay wall? Apologies if so.

Best regards,
DDM

 

[happy-diver]

I don't plan on staying on this treatment permanently, but I have some deco dives planned this year. Any advice?

my dive plan would be to get off the stuff before the dives if that's reasonable


I cried every day for a month, when my old mans third hip replacement, snapped out of his femur
and when he finally kicked the bucket three months later I was elated, dementure be gone forever

Able to tackle it all by my lonesome, natural high with drugs I manufactured myself, not at Walters

I already drank ginger beer, then upped my dose to incredible levels, so maybe sugar did it for me
and packing up of the house for 4months

Then, I imagine your father to be younger