Posted by zeugma on May 8, 2004, at 20:35:04
In reply to Re: ok, here's what my pdoc said » zeugma, posted by Questionmark on May 8, 2004, at 19:36:58
<Hi. Since you seem to have severe anxiety, i would increase the Klonopin dosage regardless of what else you do (as long as you're not tOO afraid of physical dependency, though i think it's worth it anyway).
Beyond that, my suggestion would be to add in clomipramine (Anafranil) since you're already on a TCA and the side effects would probably not be as severe (and since you already appear to be able to tolerate TCAs' side effects fairly well). Also, you sound as if pro-NE effects are beneficial to you, which is another reason to go with the clomipramine over the Lexapro. If you find that the clomipramine is not suitable or helpful enough, then you should move to the Lexapro. Furthermore, it would be easier to move from nortriptyline to clomipramine and then Lexapro than from nortriptyline to Lexapro to clomipramine.
Good luck. >Thanks, ? (not questioning your sincerity, merely expressing my gratitude)
It was my thought exactly that i could substitute 25 mg of clomipramine for 25 mg of nortriptyline, and then later, if the clomipramine worked, deconstruct it into Lexapro. He said that clomipramine had more interactions w/ other meds than lexapro, and that was his main reason for favoring the Lex. Also, he said that clomipramine was much more sedating than nortriptyline, and as my depression currently is marked by prominent vegetative signs (exhaustion, slowed movement and thought, anhedonia) that the lexapro would work better than clomipramine. And theoretically, lex with a diminished dose of nortriptyline plus strattera leaves me with substantial pro-NE effect, simulating an action of clomipramine anyway. But he left the choice up to me. he said switching in 25 mg clomipramine with 25 mg nortriptyline would be feasible.
About the klonopin: he wrote me a prescription for double the amount i currently take (ie, for 1.5 mg/day). I had wanted to switch klonopin in for another benzo, because of a possible depressogenic effect (he actually brought this up, but it was in my notes, of course) but, as he put it, he wanted to move one chess piece at a time. but he was clearly indicating that my next move, after lowering the nortriptyline (and giving the dose reduction until Monday or Tuesday to kick in) my next move could be to up the Klonopin. I take his writing the prescription for 1.5 mg as indicating that, if I chose and consulted with him, I could either up the klonopin, add clomipramine (since it isn't a controlled substance, he could call in a script) or open the Lexapro starter pack and cut a pill in half (or quarters, or take the whole pill as the pack directs). Or keep the status quo for a little longer. A lot obviously depends on my mood between now and next week (currently awful, unsurprisingly). But I agree with your reasoning as to how to sequence the changes, while also seeing his point about the Lexapro being less sedating. It's the weekend, so my anxiety is lowered while the fatigue, anhedonia, etc., are more subjectively distressing. If the Klonopin is contributing to these symptoms, which it may well be, it's best to keep it where it is for the moment.
As for dependency, that is not a consideration. I have ADD, so i will always need Strattera or a stimulant, and I actually fear dependency from SSRI's as much as dependency on benzos. Besides, my pdoc knows my history of social phobia and he also knows that I have tried MANY, MANY other approaches to resolve it (CBT, Prozac, Zoloft, Buspar, years of conventional therapy), and I think that in his mind it is preferable to give Klonopin a good run for its money before trying a MAOI (I concur with his reasoning here, as I tolerate TCA's pretty well and NE reuptake inhibition is therapeutic for me).
poster:zeugma
thread:343353
URL: http://www.dr-bob.org/babble/20040505/msgs/344905.html