Posted by SLS on January 29, 2013, at 21:56:56
In reply to My Anxiety - the end of the road, posted by jono_in_adelaide on January 29, 2013, at 20:46:21
> I'll start by saying that I am very lucky, that my depression is very well controlled by the cocktail of reboxetine, sertaline and risperidone.
>
> However, I am still often bothered by disabeling anxiety, even when taking Xanax 1mg three times a day
>
> Thinking about my options, i have come up with the following
>
> - Drop sertaline and risperidone and substitute mirtazapine 30-45mg at night. I have never felt that SSRI's do much for me, and I'm wondering if mirtazapine might be better against anxiety than low dose risperidone (1.5mg at bedtime)
>
> - Drop sertaline and reboxetine and start nardil with or without nortriptyline. I'm sure Nardil would help the anxiety, but the side effects worry me, I get no side effects from my current drugs apart from a bit of dry mouth and delayed orgasm (sory if that was TMI)
>
> - Change the 1mg alprazolam tid to 1mg clonazepam tid (clonazepam is both more potent and longer action, so I'd effectively be giving my self a dose increase of benzo) I worry that this might be the slippery slope to ending up like Elvis.
>
> Any thoughts or comments or advice anybody could offer?
Perhaps substituting nortriptyline for reboxetine makes sense at this juncture. I question the degree to which reboxetine can address anxiety. I am concerned that it might actually be contributing to it. I am guessing that you are using the risperidone for 5-HT2a antagonism, but nortriptyline might be a better fit. If you need the 5-HT7 antagonism, you could continue with risperidone or switch to Latuda. I find nortriptyline to be more pleasant and calming than the more potent and selective NRI, desipramine. You know that I am not a big fan of reboxetine, mostly because the statistical and anecdotal data are not that impressive. However, in addition, my personal experience with reboxetine was disastrous. It precipitated a severe anxious and suicidal depressive state. I was ready to die. Desipramine does not affect me that way.Is there any reason why you can't add the mirtazapine first, and then attempt to discontinue the other drugs sequentially? Mirtazapine might work in concert with sertraline in a way similar to the "rocket fuel" combination using Effexor. For what it is worth, I did better with Effexor + nortriptyline than with sertraline + nortriptyline.
Regarding Nardil, it might make a good monotherapeutic substitute for your present treatment. I do better when I use nortriptyline in combination with Nardil, but I find that hypotension and urinary retention become more problematic. It is too bad that Zyprexa produces so much weight gain and diabetes. It might otherwise work well with Nardil for anxious or bipolar depressions. As it is, you might expect a certain amount of weight gain with Nardil alone. For refractory GAD or SA, adding clonazepam to Nardil would be an interesting choice.
You might want to try substituting nortriptyline for reboxetine, perhaps using a cross taper/titration first, and determine which of the two works better for you. You could then add mirtazepine if necessary. I would leave Nardil for last, only because it would preclude your use of sertraline and perhaps even mirtazapine. I am not aware of the use of an MAOI in combination with mirtazapine. I would think that serotonin syndrome would be less of a concern than a hyperadrenergic reaction. I am not sure.
You'll figure it out.
- Scott
Some see things as they are and ask why.
I dream of things that never were and ask why not.- George Bernard Shaw
poster:SLS
thread:1036804
URL: http://www.dr-bob.org/babble/20130124/msgs/1036822.html