![[dr. bob]](/dr-bob-sm.gif)
Dr. Bob is Robert Hsiung, MD,
bob@dr-bob.orgShown: posts 1 to 16 of 16. This is the beginning of the thread.
Posted by becksA on August 13, 2003, at 9:43:26
I've got an appointment with my doc soon, I need to know what I should try next for my social anxiety...ive been doing a lot of reading on here ...is klonopin the answer...or zoloft...if i didn't have to go through the nasty side effects of a SSRI that would be great but i just want what works best for those super uncomfortable social situations that i have been avoiding so often.
Posted by cosis on August 13, 2003, at 14:55:45
In reply to Lost in SAD, which med really is BEST?, posted by becksA on August 13, 2003, at 9:43:26
> I've got an appointment with my doc soon, I need to know what I should try next for my social anxiety...ive been doing a lot of reading on here ...is klonopin the answer...or zoloft...if i didn't have to go through the nasty side effects of a SSRI that would be great but i just want what works best for those super uncomfortable social situations that i have been avoiding so often.
I say if your SAD is severe try Nardil, if it's just uncomfortable in social situations I would know which would be best.....Mine is severe though
Posted by becksA on August 13, 2003, at 16:26:37
In reply to Re: Lost in SAD, which med really is BEST?, posted by cosis on August 13, 2003, at 14:55:45
I have read good things about Nardil on here, but what's up with the special diet...how limited is it and is it really worth it?
Posted by becksA on August 13, 2003, at 16:27:03
In reply to Re: Lost in SAD, which med really is BEST?, posted by cosis on August 13, 2003, at 14:55:45
Also, how severe would you say severe really is?
Posted by Ame Sans Vie on August 13, 2003, at 22:17:55
In reply to Re: Lost in SAD, which med really is BEST?, posted by becksA on August 13, 2003, at 16:27:03
Hi,
Social phobe here since age 11, now 20 years old. I've tried just about everything out there, so I can give you the basic rundown. I'll try to be as objective as possible, though there are certain medications that I definitely have strong opinions about and I won't hide that fact. :-)
~SSRIs
Zoloft, Celexa, Lexapro, and Prozac are probably the most useful SSRIs for social anxiety disorder, though Paxil and Luvox are occasionally helpful. I personally detest Paxil and Luvox due to the awful side effects I experienced on them (apathy, sexual dysfunction, weight gain, unable to think clearly, etc.), and also because of the absolutely horrid withdrawal. About three years after my last trial of Paxil, I still have the occasional "brain zap" -- something I experienced every two or three minutes during acute withdrawal from both Paxil and Luvox.
Zoloft wasn't good for me as it nearly drove me to suicide, but I think there must be something about Zoloft in particular that clashes with my genes. One of my aunts had a very similar reaction to Zoloft years ago, and another aunt found it made her extremely angry for no reason. But I hear it can be pretty good for SP if you can tolerate it.
Prozac, Celexa, and Lexapro are (statistically speaking) the easiest of the SSRIs to tolerate, regarding their side effects. Prozac is somewhat stimulating, and may be especially good if your SP occurs with a lack of energy, obesity, oversleeping, etc. The only time I ever tried it, it didn't do a thing for me, though. But I also experienced no side effects with it, which was a definite plus.
Celexa and Lexapro are really not much different to many people (Lexapro is just half of the Celexa molecule; purportedly the 'active' half, with fewer side effects). For me, though, Celexa was fairly difficult to tolerate while Lexapro was extremely easy to. The main problems I had with Celexa were apathy and sexual dysfunction, but with Lexapro, the apathy was pleasantly absent. It helped my depression and SP symptoms considerably, though I eventually decided I couldn't continue taking it due to sexual side effects.
~Tricyclics
The tricyclic antidepressants, as a general rule, aren't effective for SP. Of this particular class, I've tried amitriptyline, doxepin, and clomipramine. None of them were at all helpful in any way for my anxiety, though they did help slightly with my depression, and the side effects (especially the anticholinergia, which produced horrible dry mouth, urinary retention, and occasional confusion) weren't at all tolerable.
~MAOIs
Only three MAOIs are currently available in the U.S. -- Nardil, Parnate, and Eldepryl (though there is also an antibiotic called Zyvox which possesses MAO inhibition properties). Nardil is often said to be the best medication available for SP, and I know it has helped a lot of people, but for me personally Nardil did nothing but force me to avoid cheese and alcohol and run to the doctor everytime I had a cough because OTC cough syrup was on the restricted food and drugs list. Then there were the side effects... sexual dysfunction and orthostatic hypotension. I haven't tried Parnate or Eldepryl, but I hear Parnate can be quite effective (especially if you are lethargic, overweight, and depressed)... I haven't heard much about Eldepryl for SP.
My advice is to avoid the MAOIs until you've failed trials of at least four of the less troublesome medications -- unless your SP is particularly severe (i.e. you have avoidant personality disorder; read the critera for this disorder here: http://www.psychologynet.org/avpd.html). If you fit the criteria for AvPD, then Nardil or Parnate should probably be one of the first medications tried (certainly not the first, though).
Since you asked about the diet specifically, I suppose I should interject here that it's not all that hard to follow, and oftentimes people are able to get away with eating restricted foods, as long as they don't overdo it.
~Atypical Antidepressants
I personally haven't spoken to one person whose SP has been helped by Effexor or Remeron, though Effexor is FDA-approved to treat this disorder. My experience with it was pretty neutral -- no side effects, but no therapeutic effects. As for Remeron, I had no therapeutic effect, but definite side effects (sedation, irritability).
I've heard of a few people being helped by Serzone, though, IMHO, it should not by any means be one of the first medications tried as it doesn't have a very high success rate. My experience with it was the same as my experience with Effexor. Trazodone is an older medication related to Serzone that, while a poor antidepressant, is a great sleep-aid.
Wellbutrin has also been reported to help occasionally, especially for depressive symptoms and lack of confidence/assertiveness associated with SP. It generally doesn't do much (if anything) for the anxiety itself, though. In fact, it tends to exacerbate anxiety in the majority of people who take it. So I feel its place in treating SP mainly lies in boosting confidence and energy once the underlying anxiety is properly addressed and treated.
~Benzodiazepines
By far the most reliable medications for social phobia are the benzodiazepines Klonopin and Xanax. Xanax has a bit more of an antidepressant effect than Klonopin, if that's what you need. Both medications begin working immediately, unlike any of the medications I've discussed up to this point. Because of this instant-gratification, many doctors see them as "addicting", but a sensible psychiatrist sees them as light at the end of the tunnel. Any troublesome side effects are mild (drowsiness, dizziness, mild euphoria) and generally disappear within a few weeks of continued use.
Klonopin was the drug that originally saved my life. I always preferred the effects of Xanax, but didn't like the four-five times daily dosing that was required -- so when Xanax XR was released in June, I immediately wanted to try it. I switched from my Klonopin to Xanax XR three weeks ago and have been doing just great on it, though I wouldn't say that either one is any better for SP than the other. It's a matter of personal preference.
Some people prefer other benzodiazepines -- I've heard people having great success with Valium and Ativan in particular.
I am very passionate about benzos being a first-line treatment for social phobia. The best way to go, IMO, is to start off with one of the more benign SSRIs (Lexapro would be my choice) and a flexible dose of Klonopin or Xanax (XR). This way, you have immediate relief with the benzodiazepine while you're waiting for the other medication to work. And if the other medication doesn't end up working, you can stay on the benzodiazepine through all your med trials so you're never untreated.
Though I take three psychiatric medications currently, only one is specifically for my social phobia, agoraphobia, and panic disorder, and that's the Xanax XR. I feel that once you've failed a trial of at least two SSRIs, an MAOI, Effexor, Serzone, and a few mood stabilizers, benzodiazepine monotherapy should be considered. Unfortunately, I wasn't afforded that option until I had failed often painful trials of dozens of medications.
Some benzos are pretty much only used as sleeping pills. In the U.S., these are Halcion, Dalmane, Restoril, Doral, and ProSom. These can be helpful if you have insomnia, or if a medication causes insomnia, though usually a different sleep-aid, such as trazodone, Remeron, Elavil, Benadryl, Ambien/Stilnox, Sonata, or Imovane, is used.
~BuSpar
BuSpar is an anxiety drug in a class of its own -- it doesn't begin working immediately like the benzos, and it doesn't cause sedation. Unfortunately, it also usually doesn't work, lol. And it's especially useless in most cases of social phobia. I tried it at 90mg/day for a while, and it did have an effect, but not on my anxiety -- it helped me to better control my temper.
~Barbiturates
If you don't count reserpine, barbiturates are really the original tranquilizers. Until the first benzodiazepine, Librium, came on the market in 1962, the barbiturates were very widely prescribed for anxiety, epilepsy, and insomnia. The benzos pretty much replaced them entirely due to their much better safety profile. Barbs are extremely dangerous in overdose, while benzos will only cause death in enormous amounts (unless combined with other depressant drugs, such as alcohol).
Still, there are some people today who need to take barbiturates. Most of these are epileptics who take phenobarbital to control their seizures, or migraine sufferers who take butalbital because nothing else touches the pain. Some still do take them for anxiety and insomnia though. Phenobarbital is most "popular" for anxiety because of its long duration of action (6-8 hours); short-acting barbiturates like secobarbital, amobarbital, and Tuinal (a combination of secobarbital and amobarbital) are more commonly used for sleep. There are also ultra-short acting barbs (i.e. thiopental, methohexital) which are used in a hospital setting as adjuncts to general anesthesia.
~Carbamates
These include Equanil and Soma. The latter is usually prescribed only as a powerful muscle relaxer, but in the body it metabolizes into meprobamate, the active chemical in Equanil. Equanil was used a lot in the 50's and 60's to treat anxiety, but, like the barbiturates, fell out of favor when the benzodiazepines came to town. I hear it's making a slight comeback though, and it *is* very effective.
~Beta-Blockers
Inderal and Tenormin are the most often used beta-blockers for social anxiety, but they're only for as-needed use for a specific subtype of social anxiety -- performance anxiety. Many musicians use them before going onstage. They don't have an effect in the brain to quell anxiety, but they reduce blood pressure and heart rate which may help to put one's mind at ease before public speaking or performance.
~Mood Stabilizers
Though not technically a mood-stabilizer, lithium (an anti-manic) may be somewhat helpful in treating SP -- especially as an augmenting agent when you've achieved a partial response to an antidepressant.
Of the seven more well-known mood stabilizers (all of which were originally developed to treat different forms of epilepsy), those with the most promise to help with SP are probably Neurontin, Lamictal, and Topamax. There is research supporting the use of Neurontin and Topamax in treating SP, and a lot of anecdotal evidence of the effectiveness of all three medications. I have yet to hear personally of anyone getting away with using a mood-stabilizer alone to treat generalized SP.
Neurontin normally must be taken at high doses to exert an anti-anxiety effect. I've taken it at doses up to about 4,800mg/day and found that it had a mildly relaxing feel to it. I wasn't prescribed it for social anxiety at the time though; this was just a pleasant "side effect" that occurred while I was using it to treat fibromyalgia pain.
Lamictal has a pretty good antidepressant effect for many people. I certainly believe it has potential to help SP based only on the fact that I had to discontinue it two weeks into taking it due to side effects that reminded me *way* too much of the SSRIs.
I haven't tried Topamax personally, but there are some fairly recent studies suggesting its usefulness in the treatment of SP. Reading about the experiences of others, I gather that most people lose weight while taking it (which could of course be considered a positive or negative effect). Its main drawback from what I understand is its tendency to cause a sort of "brain fog"... difficulty finding the right words for things is a one of the major downsides, I hear.
Of the four other more widely-used mood-stabilizers, Depakote, Tegretol and Trileptal probably show the most potential in being helpful for SP (and Trileptal's effects are pretty much exactly the same as Tegretol's -- it's just a newer form of the drug that requires less blood monitoring). I've tried Depakote and Trileptal myself -- Trileptal had no appreciable effects at all; Depakote didn't help with my anxiety, but was extremely helpful in controlling my adolescent temper (I was a 16-year-old ADHD/ODD kid, every mother's dream lol, when I was taking it).
The last mood-stabilizer worth mentioning is Gabitril -- a GABA-B reuptake inhibitor (i.e. it increases available GABA, the brain's major inhibitory neurotransmitter, at the B subreceptors in the same way that SSRIs increase the availability of serotonin). While improved GABA functioning is no doubt helpful in treating anxiety (all the benzodiazepines act mainly to increase the actions of GABA), it's GABA-A that seems to be more helpful with anxiety, and I haven't heard of anyone being successfully treated for any anxiety disorder with Gabitril yet. I *have* heard it can be useful for depression, though.
~Antipsychotics
These are another one of those "only-try-this-if-all-else-has-failed" medications. They have some pretty nasty side effects (e.g. sedation, weight gain, loss of libido, diabetes, movement disorders [sometimes permanent]), and it's pretty rare that they're helpful to someone with SP (with the exception of low-dose amisulpiride -- unfortunately not available in the U.S.).
~Opioids
Many doctors are extremely reluctant to prescribe narcotic painkillers for *pain*, so you can imagine it's difficult to convince your psychiatrist to let you try one for a psychiatric condition. But I've actually been prescribed several opioids psychiatrically, and currently take Ultram, which is an opioid that also has serotonin and norepinephrine reuptake inhibition properties. These two things together make it feel, to me, sort of like a combination of hydrocodone (Vicodin) and doxepin, but without the nasty tricyclic side effects and without development of tolerance. I take it specifically for my depression and OCD at 100mg four times daily, but it helps my SP quite a bit as well. I know this to be true because I find my anxiety is not nearly as bad in the morning before I take my Xanax as it was before I began Ultram.
So if you're going to consider the opioid route of treating your SP, Ultram is probably your best option. Three main reasons for this -- 1) it's not a controlled substance in most states, so doctors aren't afraid to prescribe it, 2) it has that added action on serotonin and norepinephrine that most other opioids lack, and 3) most other narcotics that are useful and that a psychiatrist may be willing to try contain either acetaminophen, ibuprofen or aspirin (e.g. Vicodin, Vicuprofen, Percocet, Percodan) which can cause problems taken long term. So unless your doctor is willing to give morphine, methadone, oxycodone, or buprenorphine a try, Ultram is definitely the way to go.
~Psychostimulants / Strattera / Edronax
These don't usually help social anxiety directly, and often make anxiety worse, like Wellbutrin. But also like Wellbutrin, these drugs are great for increasing assertiveness, confidence, and motivation in social phobes once the anxiety itself is under control. I don't have any experience with Strattera or Edronax, which are both norepinephrine reuptake inhibitors, but I imagine they could be helpful.
The place to start with the stimulants, should you end up needing one, is probably Provigil (Alertec in Canada). It is a very mild stimulant that doesn't interfere with sleep (i.e. won't cause insomnia) or appetite, and can provide a nice mood-lift, decrease fatigue, and, some say, improve memory. Doctors are less reluctant to prescribe this than most other stimulants because its abuse potential is quite low. Unfortunately, my tolerance is naturally high for most drugs and the dose required for me to receive any real benefit from this drug was five times the recommended dose. That would have been okay, and it was great for a few days, but then it started giving me very bad headaches, so I had to discontinue. One other warning: if you want to try Provigil, be sure to have excellent insurance. It's ungodly expensive. There is a less expensive drug that's very similar to Provigil, called Olmifon, but it's not marketed in the U.S.
If Provigil/Alertec isn't enough, then the next step up is an amphetamine. These include Adderall (levo-amphetamine + dextro-amphetamine; the old diet drug Obetrol repackaged and marketed toward ADHD patients), Dexedrine (dextro-amphetamine), and Desoxyn (dextro-methamphetamine). All can be useful, though different people tend to respond more favorably to different ones.
Adderall and Dexedrine are the most commonly employed, presumably because of the stigma attached to methamphetamine and the resultant fear doctors have of prescribing it (though the truth is, it isn't really any more abuseable than Adderall or Dexedrine). Their effects are quite subjective, but one thing that's pretty consistent is Adderall's tendency toward more peripheral effects (i.e. raised blood pressure, heart rate) than the other pharmaceutical amphetamines. This is surely due to the levo-amphetamine it contains; I take dextro-amphetamine sulphate SR (sustained-release) currently and find it to be less anxiety-provoking than Adderall. Before I switched to Dexedrine, I was on Desoxyn for a while. It also seems to lack the negative effects of Adderall, but, for me, it was slightly less helpful for ADD symptoms than Dexedrine. All the amphetamines make me feel more sociable, though.
There's also Ritalin, which is a non-amphetamine powerful stimulant. I found its peripheral effects to be wayyyyyy too strong, though. It was literally as if I had injected several thousand milligrams of caffeine into a vein. I don't normally have generalized anxiety, but on Ritalin I sure did!
Finally, there's Cylert. It takes a few weeks before it begins to work, and it doesn't work for everyone. I wouldn't recommend this one, though, and most doctors don't like to prescribe it either, unless absolutely necessary -- long-term use of it can lead to very serious liver problems that can result in need for transplantation and death.
~Dopamine Agonists
Mirapex (Mirapexin in the U.K.) and Requip are two drugs normally used to treat Parkinson's disease. They work by enhancing the effects of dopamine, which, for most, results in an increase in mood, motivation, and libido. Because of these effects, they can be great for counteracting the side effects of many antidepressants.
I've only tried Mirapex, and it was absolutely wonderful for a few months. But then I began having what the prescribing information for the drug refers to as "sleep attacks". I would just feel extremely tired out of nowhere, and occasionally just nod off to sleep -- obviously this was no good, and I had to discontinue. Too bad, though, because Mirapex is a wonderful medication. Had I been taking the Dexedrine that I take now at that time I may not have had that problem, so I'm now considering trying it again, or perhaps trying Requip.
~Other
There are lots of other non-prescription ways to approach this problem, including herbal, nutritional, and homeopathic treatment. If you'd like any info on these, either let me know here or feel free to e-mail me by clicking my name above.
Hope this helped!
Posted by SLS on August 13, 2003, at 22:39:58
In reply to Re: Lost in SAD, which med really is BEST? » becksA, posted by Ame Sans Vie on August 13, 2003, at 22:17:55
Excellent post!
Thank you.
- Scott
Posted by becksA on August 14, 2003, at 10:51:45
In reply to Re: Lost in SAD, which med really is BEST? » becksA, posted by Ame Sans Vie on August 13, 2003, at 22:17:55
wow thank you so much for the help....after all that, i think im going to mention klonopin and lexapro as possiblities....appointment in 6 days!
Posted by becksA on August 14, 2003, at 11:04:56
In reply to Re: Lost in SAD, which med really is BEST? » becksA, posted by Ame Sans Vie on August 13, 2003, at 22:17:55
now that i do a little research on lexapro however, seems like its more for depression? that's not as much my problem as the social anxiety is....
Posted by Ame Sans Vie on August 14, 2003, at 12:34:33
In reply to Re: Lost in SAD, which med really is BEST?, posted by becksA on August 14, 2003, at 11:04:56
All the SSRIs are more or less equally effective for a very wide range of disorders -- depression, social anxiety, obsessive-compulsive disorder, panic disorder, and generalized anxiety are the ones they're most commonly prescribed for. But they are all also sometimes useful for bipolar II, kleptomania, borderline personality disorder, alcoholism, migraine, post-traumatic stress disorder, cataplexy, Tourette's syndrome, diabetic neuropathy, schizophrenia, premature ejaculation, trichotillomania, and levodopa-induce dyskinesia. Prozac is additionally sometimes effective for bulimia, anorexia, ADHD, obesity, and narcolepsy.
So what I'm essentially trying to say is that, for the most part, the SSRIs are interchangeable and can all be used to treat the same disorders. It's more a matter of subjective side effects and personal preference that plays a role in deciding which drug you end up taking. Here are some links to information pertaining to Lexapro in treating SP:
http://www.docguide.com/news/content.nsf/news/8525697700573E1885256D59005A30A8 -- "Citalopram Therapy Effective in Treating Social Anxiety Disorder and Comorbid Major Depressive Disorder"; technically, this link is about Celexa (citalopram), but as I mentioned in my last post, Lexapro (escitalopram) is really just a more effective version of Celexa with fewer side effects.
http://www.docguide.com/news/content.nsf/news/8525697700573E1885256CFA005DD559 -- This study is entitled "Escitalopram Effective in Social Anxiety Disorder for Up to 36 Weeks", but remember that time limit is put on there only because that's all the longer the study lasted. In practice, SSRIs, when they work, normally work at least a few years, and at best the rest of your life.
http://www.docguide.com/news/content.nsf/news/8525697700573E1885256B84006FB998 -- "Lexapro (Escitalopram) Significantly More Effective Than Placebo in Social/Generalized Anxiety and Panic Disorders"
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=9184626&dopt=Abstract -- "Role of serotonin drugs in the treatment of social phobia."
Here are some interesting studies on the use of benzodiazepines, Klonopin (clonazepam) in particular, in SP:
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=8120156&dopt=Abstract -- "Treatment of social phobia with clonazepam and placebo."
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=1757453&dopt=Abstract -- "Long-term treatment of social phobia with clonazepam."
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=2228982&dopt=Abstract -- "Clonazepam for the treatment of social phobia."
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=2372756&dopt=Abstract -- "Social phobia and clonazepam."
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=2186023&dopt=Abstract -- "Clonazepam in the treatment of social phobia: a pilot study."
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=11043885&dopt=Abstract -- "A comparison of the efficacy of clonazepam and cognitive-behavioral group therapy for the treatment of social phobia."
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=8994456&dopt=Abstract -- "A 2-year follow-up of social phobia. Status after a brief medication trial."
Here are some more studies you may find interesting, which pertain to the use of all sorts of drugs in treating SP:
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=12607230&dopt=Abstract -- "A review of 19 double-blind placebo-controlled studies in social anxiety disorder (social phobia)."
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=11206035&dopt=Abstract -- "Benzodiazepines and anticonvulsants for social phobia (social anxiety disorder)."
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=7782272&dopt=Abstract -- "Social phobia: a pharmacologic treatment overview."
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=12900950&dopt=Abstract -- "Pharmacological treatment of social anxiety disorder: A meta-analysis."
http://www.socialfear.com/ -- This page goes into a fair amount of detail on social phobia, and discusses many medications commonly used to treat SP.
Finally, here's an interesting article I thought you'd like to read that kind of ties in with what I'm saying (Note, citalopram, but not escitalopram, is mentioned in this article; this is because the article was written before Lexapro was released last September / Also note, this article mentions the generic names of several drugs, and here's what they are -- paroxetine=Paxil, sertraline=Zoloft, citalopram=Celexa, fluoxetine=Prozac, clonazepam=Klonopin, buspirone=BuSpar, gabapentin=Neurontin, bupropion=Wellbutrin/Zyban, phenelzine=Nardil):
~~~~
Choosing the Right SSRIs for Social Phobia
Carl Sherman
Contributing Writer
In May 1999, paroxetine became the first medication to be approved by the Food and Drug Administration as a treatment for social phobia.Although selective serotonin reuptake inhibitors (SSRIs) are a standard first-line treatment among prescribing physicians, paroxetine is not at the top of the list. Nor, for that matter, is any single agent sufficient in many cases.
"The greatest amount of available data at this point is with paroxetine, but it's likely all SSRIs are similarly effective," said Dr. Mark Pollack, director of the anxiety disorders treatment and research program at Massachusetts General Hospital, Boston. "We don't have data, such as head-to-head trials, that say one [SSRI] is better than another for social phobia."
Dr. Bruce Lydiard, director of the mood and anxiety program at the Medical University of South Carolina, Charleston, said he tailors the drug to the patient. For patients who have sleep problems, paroxetine is a likely option; if lethargy is an issue, a more activating agent such as sertraline or citalopram may be more appropriate.
Although Dr. Lydiard uses fluoxetine, he is likely to opt for an agent with a shorter half-life if the patient has had no prior experience with SSRIs.
In addition to their apparent efficacy in social phobia itself, SSRIs have a broad spectrum to recommend them, Dr. Lydiard said. "You see a fair amount of comorbid major depression, posttraumatic stress disorder, or panic in these patients."
"Start low, go high" seems to be a common plan. Although intolerance to stimulation and other SSRI side effects is less pronounced than when the drugs are used for panic disorder, some patients may be exquisitely sensitive to bodily sensations or "quite hypochondriacal" and require a slow escalation of the dose, Dr. Lydiard said. He said he often begins with one-fourth the dose he'd use for depression (for example, 5 mg of fluoxetine or 12.5 mg of sertraline), but may end 1˝ times higher, he said.
"I'm pretty cautious," agreed Dr. Franklin R. Schneier, associate director of the anxiety disorders clinic at New York State Psychiatric Institute in New York, who says he typically initiates social phobia treatment with half the usual starting dose for depression (for example, 10 mg of paroxetine), reaching the antidepressant level in 3-4 weeks. "At that point, if I'm not seeing any benefit or side effects, I might go up some more.
"For most people with social phobia, the situation is very chronic. They've had it for 5-10 years and are not in an immediate crisis, so there's no pressure to push the dose and make a quick decision. You have the luxury of a reasonably full trial."
But this may require some patience. "It may take weeks or months to get a full, comprehensive reduction in distress," Dr. Pollack said. "It takes a while [for the patient] to trust the anxiolytic effects of the medication and to expose himself to difficult situations."
Although there are not much data defining the length of an adequate trial, Dr. Pollack will consider a substantial dose increase if there has been no progress after 4 weeks, and then augmentation if not much has happened 2-3 weeks after that.
In the long run, augmentation often is necessary. "The target is getting the patient as close to well as possible. We want to push patients until they're pretty comfortable in social situations and able to do whatever they want to," he said. At least half will not achieve this goal with SSRIs alone.
Most often, this means an anxiolytic. "Sixty percent of the people I treat get some benzodiazepines," Dr. Lydiard said. "Sometimes just knowing it's in his pocket keeps the patient from panicking."
Among the benzodiazepines, clonazepam is a typical first choice. Dr. Pollack said that he may add the drug at the outset of treatment—before the SSRI—or use it to cover stimulant effects of the SSRI in a patient who is unusually sensitive. Buspirone is an alternative when a benzodiazepine is contraindicated. A more recent option is gabapentin. "My experience with this drug has been quite positive. ... It's a useful addition," he said.
Dr. Lydiard noted that he may use bupropion to augment an SSRI if improvement is inadequate or to manage sexual side effects.
Switching rather than augmentation has its place, particularly if the response to the first drug is negligible. Dr. Lydiard is likely to go to another SSRI, while Dr. Schneier will more often chose a different class altogether, either clonazepam (if comorbid depression or dependence is not an issue) or an MAO inhibitor, particularly phenelzine. That will depend on how amenable the patient is to following a diet and how trustworthy the person is. "I wouldn't be comfortable [giving an MAO inhibitor] if a patient is too impulsive or has a history of noncompliance," he said.
The efficacy of drugs shouldn't obscure the role of cognitive-behavioral therapy (CBT) in the role of social phobia. Dr. Schneier, who is trained in this modality, said he often recommends it as a first-line approach for someone who has not had it before. Those patients for whom he prescribes medication will also be getting some CBT, "in a formal or informal way," perhaps through his encouraging exposure to difficult situations.
In Dr. Schneier's experience, the response to CBT is less dramatic than to medication, but it tends to be longer lasting. And when an SSRI alone is inadequate, the addition of CBT may make adjunctive medication unnecessary, he said.
~~~
This article brings up another quite important topic -- cognitive behavioral therapy. CBT combined with medication is always the best way to go, and gives you a much better chance of achieving complete remission and even one day being able to discontinue medication.
Any more questions, I'm here! :-)
Posted by McPac on August 15, 2003, at 16:01:33
In reply to Re: Lost in SAD, which med really is BEST? » becksA, posted by Ame Sans Vie on August 13, 2003, at 22:17:55
"Lamictal has a pretty good antidepressant effect for many people. I certainly believe it has potential to help SP based only on the fact that I had to discontinue it two weeks into taking it due to side effects that reminded me *way* too much of the SSRIs".
>>>>>>>>>>Ame, did Lamictal induce Anger in you? (It did in me!)
Posted by Ame Sans Vie on August 15, 2003, at 16:43:42
In reply to Ame, Re: Lost in SAD, which med really is BEST?, posted by McPac on August 15, 2003, at 16:01:33
I didn't take the Lamictal long enough to notice any beneficial effects... I stopped it the very moment I noticed that all-too-familiar "Paxil-brain-buzz", lol.
Posted by wingedcat on August 16, 2003, at 4:25:20
In reply to Lost in SAD, which med really is BEST?, posted by becksA on August 13, 2003, at 9:43:26
SSRI's personally made me worse.
Klonopin got me out of a really rough spot. It didn't take away the anxiety completely, but it made my panic attacks stop and things got quieter and more managable. I am weaning off of it now after 6 months because the side effects of memory disturbance are starting to really bother me. But during this time while I've been on it, I've been meeting with a therapist weekly and learning new coping skills. I think that having 6 months where I wasn't as anxious really helped me to learn how to feel better in the long run. I don't feel like I need the Klonopin anymore (but you have to wean off slowly or risk seizures).
I have heard people have really good effects with Nardil, but you have to be pretty careful with your diet on that and I'd be sad cutting out some of my favorite foods. Wellbutrin worked for some aspects of social anxiety for me by lifting depression and making me feel more awake. The anxiety and depression really play off and amplify each other, and I think if you treat one then you can work on minimizing the other.
I hope whatever you decide to try helps you out :)
Posted by becksA on August 16, 2003, at 14:02:22
In reply to Re: Lost in SAD, which med really is BEST?, posted by wingedcat on August 16, 2003, at 4:25:20
thanks alot....i appreciate the response. im just worried that when i ask for klonopin (which is what im going to do) the doc might not be anxious to try that before some dumb SSRI that's just gonnna make me sick again. im your typical young college student and they always think twice when you mention abusable drugs. :(
Posted by judy1 on August 16, 2003, at 20:41:57
In reply to Re: Lost in SAD, which med really is BEST?, posted by becksA on August 16, 2003, at 14:02:22
I truly hope you get a sympathetic doc and are given a benzo (klonopin and xanax are my favorites) over an SSRI. Sometimes Internists are more generous with benzos then shrinks (IMO), so you may want to give your primary doc a try if you're unlucky with the shrink. best of luck- judy
Posted by judy1 on August 16, 2003, at 20:43:12
In reply to Re: Lost in SAD, which med really is BEST? » Ame Sans Vie, posted by SLS on August 13, 2003, at 22:39:58
Posted by becksA on August 16, 2003, at 21:10:13
In reply to Re: Lost in SAD, which med really is BEST? » becksA, posted by judy1 on August 16, 2003, at 20:41:57
yeah.....the more i think about it, the less i think he's gonna help out with a benzo :( ...i can only help my bit by being the most descriptive with symptoms i guess.
This is the end of the thread.
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