![[dr. bob]](/dr-bob-sm.gif)
Dr. Bob is Robert Hsiung, MD,
bob@dr-bob.orgShown: posts 1 to 21 of 21. This is the beginning of the thread.
Posted by becksa on May 4, 2004, at 18:46:55
Everytime we even get semi-close to the subject of a non-SSRI drug for social anxiety, he shows signs of it being out of the question. Yet I've tried everything in the book by now. Any people that have been in this situation, your advice please...I do get the feeling if I really say the right stuff he'll be game. Thanks
Posted by BobS, on May 4, 2004, at 20:42:08
In reply to Xanax - my pdoc thinks its too much! I DONT!, posted by becksa on May 4, 2004, at 18:46:55
Please find a doctor who is not benzophobic. I and many others on this board will attest to the benefits of taking that kind of action. Xanax is a fine drug when used correctly. I have a friend who has been taking Xanax for 18 years for panic without consequence.
Regards,
BobS.
Posted by chemist on May 4, 2004, at 21:30:55
In reply to Re: Xanax - my pdoc thinks its too much! I DONT!, posted by BobS, on May 4, 2004, at 20:42:08
> Please find a doctor who is not benzophobic. I and many others on this board will attest to the benefits of taking that kind of action. Xanax is a fine drug when used correctly. I have a friend who has been taking Xanax for 18 years for panic without consequence.
> Regards,
> BobS.i agree with Bob, very much so....benzos/xanax saved my life - there were some bad ones, restoril and dalmane coming to mind - but my experiences with ativan, valium, klonopin, and xanax, and halcion (briefly) were very, very positive overall.....follow Bob's advice! with best wishes for a speedy recovery, chemist
Posted by rvanson on May 5, 2004, at 6:24:29
In reply to Xanax - my pdoc thinks its too much! I DONT!, posted by becksa on May 4, 2004, at 18:46:55
> Everytime we even get semi-close to the subject of a non-SSRI drug for social anxiety, he shows signs of it being out of the question. Yet I've tried everything in the book by now. Any people that have been in this situation, your advice please...I do get the feeling if I really say the right stuff he'll be game. Thanks
Get a new doc.
This chump is "playing it safe".
Posted by becksa on May 5, 2004, at 21:20:58
In reply to Re: Xanax - my pdoc thinks its too much! I DONT!, posted by rvanson on May 5, 2004, at 6:24:29
ha ha.....well i haven't directly asked him as yet, i have been nice and hopeful, trying the ssri's....now im way too frustrated, i'm going to ask him straight up, if he says no, im outta there. thanks
Posted by zeugma on May 6, 2004, at 16:01:25
In reply to Re: Xanax - my pdoc thinks its too much! I DONT!, posted by becksa on May 5, 2004, at 21:20:58
hi all, this story is so common, what pdocs don't realize is that being the subject of severe and unrelenting anxiety often causes medications to stop working, it causes the dam to break so to speak, it has happened to me and i am VERY depressed right now...
Posted by rainyday on May 6, 2004, at 17:12:00
In reply to Re: Xanax - my pdoc thinks its too much! I DONT!, posted by zeugma on May 6, 2004, at 16:01:25
Here are my 2 cents: my p-doc said she wanted to treat my anxiety and panics attacks primarily; and if ultimately that treatment resulted in a benzo addiction (which was my fear I had expressed) then we would deal with that. She said I was not on a dose that would constitute an addiction, and I do check in with her regularly.
So, in my case - I was the reluctant one, and my p-doc prescribed the xanax and it has helped me so much. It all seems like worrying about nothing now - oh, no, that's why I went to the dr. in the first place :)
Posted by zeugma on May 6, 2004, at 18:56:51
In reply to Re: Xanax - my pdoc thinks its too much! I DONT!, posted by rainyday on May 6, 2004, at 17:12:00
> Here are my 2 cents: my p-doc said she wanted to treat my anxiety and panics attacks primarily; and if ultimately that treatment resulted in a benzo addiction (which was my fear I had expressed) then we would deal with that. She said I was not on a dose that would constitute an addiction, and I do check in with her regularly.
>
> So, in my case - I was the reluctant one, and my p-doc prescribed the xanax and it has helped me so much. It all seems like worrying about nothing now - oh, no, that's why I went to the dr. in the first place :)
>
well, you are very lucky, and i am happy that your symptoms have abated :)as for myself, i fear that my experience is far more common: i was put on an AD that helped the depression but not the anxiety, then was given the weak antidepressant buspirone (it is no anxiolytic) as a treatment for "anxiety." Meanwhile I had been suffering debilitating social anxiety all my life (beginning with school phobia at age 5, by the 4th grade i wanted to drop out because i couldn't handle the torment of school, i also have a severe case of ADHD which no doubt worsened the anxiety further, have spent years unemployed in my parents' apartment, have had panic attacks from the age i developed school phobia, i don't even know if the term 'anxiety' begins to cover this) and pdoc had to be coaxed into prescribing a tiny dose of klonopin (.25 mg bid) when i finally landed a full time job seven mos. ago (my first, i am 36 now)and i pleaded with his associate to let me try it because i was terrified that anxiety would incapacitate me at this job i had worked so hard to get. evn though this dosage is inadequate, he has reisted any dose increase, and constantly urges me to reduce my dose (I'm at .75 mg/day, which you can see is a negligible increase from .5 mg/day) but every bit of anxiolysis counts, and i have endured several anxiety-driven meltdowns at work anyway. two weeks i had a major catalyzing event which set off multiple anxiety alarms, and it has precipitated a terrible crisis i have experienced a relapse of asll my depressive and ADD symptoms, i am constantly trembling and fearful, and in need now of a medication overhaul (my antidepessant is no longer working). I also think Klonopin may not be the ideal benzo for a unipolar depressive, as it may be contributing to this depression which was slowly building until the recent crisis. Xanax has antidepressant properties but is an even more reviled name among pdocs who detest benzos. i am so desperate now that i am willing to try an SSRI again along with the strattera i am currently taking, despite previous failed trials and dubious efficacy in true social phobia (a severer affliction IMO than most pdocs realize, because it leads to self-contempt and frustration of a magnitude few can realize), but in my last converstaion with my pdoc (earlier this week) he again urged me to reduce my klonopin to .5 mg asap- despite my having anxiety/fear of terrible propertions! i am willing to go along with and try lexapro, but i am also going to suggest alprozalam instead of clonazepam as i believe it is less deporessogenic, and i am severely depressed at the moment as well as anxious. i have looked at a list of other pdocs here so that i am ready if he doesn't like this idea. i feel awful and am hanging on only by the realization that i want to get better at all costs and will not tolerate anything less than proper treatnment at this point because i need it. people with severe SP/avoidant personality disorder are used to being treated like doormats but my pdoc will learn that i cant handle that anymore.
Posted by harryp on May 6, 2004, at 22:05:52
In reply to Re: Xanax - my pdoc thinks its too much! I DONT!, posted by zeugma on May 6, 2004, at 18:56:51
Your stories are distressingly familiar. Psychiatrists' lack of empathy and initiative towards their patients' suffering can be remarkable.
I would lean towards lorazapam (Ativan) over Xanax--it seems to last a bit longer and you can use fewer doses.
Also, I'd like to point out that Nardil is considered great for social anxiety and depression. The MAOI's in general are very good for anxiety as well as depression. I was able to cut back to about 2mg/day lorazapam after going on Parnate.
I'm always puzzled that pdocs will blithely pass out Effexor samples, even though it causes physical dependency in 50% of users and heroin-grade hellish withdrawal in about 15%, yet stew about benzos being "habit forming"!
If Parnate went off the market I'd have to learn to synthesize it in my bathroom (fortunately I did well in O-chem!) or I'd probably be dead in a few months. THAT'S drug dependance, if you like, and it's something a lot of us deal with.
Likewise when my anxiety gets bad I literally experience physical agony--stomach cramps, chest pains, racing heart, as well as emotional pain that makes me completely nonfunctional. 1 mg lorazapam will nail one of these episodes. Am I "dependent" on this drug? Absolutely! How exactly is that a problem?
Sometimes I wonder what fantasy world pdocs inhabit during their four year residency...
Posted by zeugma on May 7, 2004, at 4:53:56
In reply to Re: Xanax - my pdoc thinks its too much! I DONT!, posted by harryp on May 6, 2004, at 22:05:52
Your advice is sound- Nardil is indicated for depression accompanied by severe social anxiety and general "phobic features" (which i have always had). As I said in another post, however, use of MAOI's rapidly seems to be becoming a lost art, and TCA's seem outre enough to most pdocs I have encountered (and who are, of course, the reason i am in this predicament). My depression is partially TCA-responsive- I did well on nortriptyline twice- it blocked the panic attacks, helped me sleep and lessened the fog a little as well as lifting my mood. So I am going to ask my pdoc for anafranil as I can titrate more easily from nortriptyline to the new drug, as well as taking a med that may be sedating enough to help me sleep. I also have narcoleptic symptoms- cataplexy- and TCA's are effective treatment for this if they are at a high enough dose, as is a pure NE reuptake inhibitor like Strattera. I take my 80 mg of Strattera in the morning, and get painful episodes of cataplexy in the late afternoon when the strattera drains away (5-hour half-life) but i don't want to up the dose of strattera as its s/e are at least as bad (for me) as a TCA- so much for new meds having less 'side effects' than old ones. That said, I would not want to discourage anyone form trying Strattera as it is a potent drug and can help.
I am going to try to explain to my pdoc, as best I can, that AD's, when they have worked, have broken up the 'ice' that clogs my brain- I mean overall patterns of thinking, general emotional tenor. Klonopin on the other hand works in a more simple way- people and things appear less frightening. It was a shock to me when i started Klon and discovered that being presented with the stimulus of a person's face didn't register as 'frightening', 'disturbing', etc. I haven't had any AD affect me on this kind of level and it has enabled me to say hello to my neighbors (for example) although I still have strong fear-reactions to people- there's more aberrant with me than just physiological perception, which is why I am pushing for anafranil or if not that lexapro- but ONLY if combined with a suitable benzo that is at an adequate dose. I'm writing this post in the midst of tears and anxiety so excuse any misspellings and /or unclarities- Nardil is next if anafranil or lexapro fails-
Posted by Joy on May 7, 2004, at 7:47:50
In reply to Xanax - my pdoc thinks its too much! I DONT!, posted by becksa on May 4, 2004, at 18:46:55
Xanax is a great med [the generic alazopram from Greenstone labs is what I take]. I also take Prozac, but the Xanax is an excellent medication for anxiety [as needed] and I use it at bedtime. I never overuse it and have not increased my dose in 4 years. Find a pdoc or doc that understands these things.
Joy
Posted by zeugma on May 7, 2004, at 21:21:06
In reply to Re: Xanax - my pdoc thinks its too much! I DONT!, posted by Joy on May 7, 2004, at 7:47:50
so as you know, i have had buckets of despair lately, crying buckets, i walked the dark way home last night from the store because i didn't want anyone to see me crying.
so i had written out some things before the session because i felt i had to be prepared. the balamce of power between pdoc and patient is a touchy thing, one likes to think that pdoc knows something we don't, if we are going to shell out cash for the session. Conversely on e may worry that a pdoc who is too 'agreeable' merely has no clue as to what he or she is doing and is trying to keep the patient happy (as opposed to well) because we are a clientele in great need. ok, so here's what happened:
i called last night to leave the message that i was 'severely depressed and anxious.' read: this was not going to be the usual ritual of chitchat about 'concentration' followed by the monthly bp check because i am on noradrenergic meds. that was the opening move.
ok, so this happened: i opened by saying that desipramine might work better than nortriptyline and strattera combined. his answer was that he wasn't sure of that. <sorry, things will get complicated> i said, welll, they are all NE reuptake inhibitors, and why be on 2 meds when 1 can do the same thing? ok, here's what he said:
Nortriptyline and desipramine work more in the brainstem, while strattera works more in the frontal lobes. He said, that's why strat is more effective for ADD than nortrip. He also said desip and nortrip are more or less interchangeable,(ie, both work mainly in the brainstem). i objected that desipramine was as effective for ADD as strattera. he agreed that such were reports, but that he wasn't sure about it ( i can only register a ? here and wonder what other experts in the field say).
ok, so he is keeping me on klon, .75 mg for now, which he agreed was a low dose. i am lowering the nortrip to 50 mg. i am going to see what happens. i have a sample pack of lex, which he told me to 'keep around.' that is one i respect in him, he does not seem beholden to drug marketers- ie he did not say i should take lex, only that it would interact less than anafranil, but he agreed that if this move (lowering nortrip) doesn't help, i can add anafranil, lex, or up the klon. what do you guys (experts and not) think? i remember Scott saying that where drugs act is as important as putastive mechanism of action, but i have seem little about this topic. it is an fascinating one though. obviously it will take a few days for the dose lowering to have a discernible effect. what my doc said did tally, though, with what i ahve observed about strat's and nortript's different effects- nortrip semed more emotional, and not in an anesthetic way, it heightens tham actually <for me>. strat seemed more alerting somehow, and i moved up quickly in my workplace than landed a new job not long afeter starting it. thoughts?
Posted by harryp on May 7, 2004, at 22:27:51
In reply to ok, here's what my pdoc said, posted by zeugma on May 7, 2004, at 21:21:06
On the whole, it sounds like you have a good doctor who takes you seriously.
He is right about norepinephrine being very active in the brainstem, but the brainstem doesn't really have much to do with mood (sleep/wake cycles--yes, which is certainly part of depressive pathology), as far as I know. I'm sure nortriptiline and desipramine also must operate on mood centers, or else they probably would be ineffective as AD's.
Sounds like your doc is open-minded, though. I hope these changes work for you!
(I'm looking at a current neuropharmacology text as I write this--it is fascinating, but the whole book could be summarized "we know little or nothing about how psychoactive drugs really work...")
You just have to keep trying something until you get results!
Posted by zeugma on May 7, 2004, at 22:46:01
In reply to Re: ok, here's what my pdoc said, posted by harryp on May 7, 2004, at 22:27:51
Yes, I have a diagram of the amine systems and norepinephrine is integral to sleep cycles- the neurons in locus coeruleus must stop firing when REM state is entered. About 15 years ago when I was an undergraduate the effect of AD's on REM was stressed as a possible mechanism by which the drugs worked on mood- i wrote a paper on how 'endogeneous' vs. 'reactive' depression could be differentiated by REM abnormalities associated with the former but not the latter, and endogenous depression was basically what TCA's were supposed to fix. That was at the tail end of the TCA era, and I think research was mostly abandoned with the advent of SSRI's, since SSRI's have very different (and I believe deleterious, but that is the subject for an entire book, "The Dream Drugstore" by J.Allan Hobson) effects on the sleep/wake cycle.
When he brought up the brainstem vs. frontal lobe speculation, I suppose it awed me too a little, at how little we know even about drugs as old as the TCA's.
Posted by harryp on May 7, 2004, at 22:56:32
In reply to Re: ok, here's what my pdoc said » harryp, posted by zeugma on May 7, 2004, at 22:46:01
Sounds like you should go back into neuroscience! That hypothesis for the distinction between endogenous and reactive depression sounds far more intellectually fruitful than the tiresome drug rep low serotonin dogma in the psychpharm books today.
I'll check out that book.
Posted by Questionmark on May 8, 2004, at 19:36:58
In reply to ok, here's what my pdoc said, posted by zeugma on May 7, 2004, at 21:21:06
> so as you know, i have had buckets of despair lately, crying buckets, i walked the dark way home last night from the store because i didn't want anyone to see me crying.
>
> so i had written out some things before the session because i felt i had to be prepared. the balamce of power between pdoc and patient is a touchy thing, one likes to think that pdoc knows something we don't, if we are going to shell out cash for the session. Conversely on e may worry that a pdoc who is too 'agreeable' merely has no clue as to what he or she is doing and is trying to keep the patient happy (as opposed to well) because we are a clientele in great need. ok, so here's what happened:
>
> i called last night to leave the message that i was 'severely depressed and anxious.' read: this was not going to be the usual ritual of chitchat about 'concentration' followed by the monthly bp check because i am on noradrenergic meds. that was the opening move.
>
> ok, so this happened: i opened by saying that desipramine might work better than nortriptyline and strattera combined. his answer was that he wasn't sure of that. <sorry, things will get complicated> i said, welll, they are all NE reuptake inhibitors, and why be on 2 meds when 1 can do the same thing? ok, here's what he said:
>
> Nortriptyline and desipramine work more in the brainstem, while strattera works more in the frontal lobes. He said, that's why strat is more effective for ADD than nortrip. He also said desip and nortrip are more or less interchangeable,(ie, both work mainly in the brainstem). i objected that desipramine was as effective for ADD as strattera. he agreed that such were reports, but that he wasn't sure about it ( i can only register a ? here and wonder what other experts in the field say).
>
> ok, so he is keeping me on klon, .75 mg for now, which he agreed was a low dose. i am lowering the nortrip to 50 mg. i am going to see what happens. i have a sample pack of lex, which he told me to 'keep around.' that is one i respect in him, he does not seem beholden to drug marketers- ie he did not say i should take lex, only that it would interact less than anafranil, but he agreed that if this move (lowering nortrip) doesn't help, i can add anafranil, lex, or up the klon. what do you guys (experts and not) think? i remember Scott saying that where drugs act is as important as putastive mechanism of action, but i have seem little about this topic. it is an fascinating one though. obviously it will take a few days for the dose lowering to have a discernible effect. what my doc said did tally, though, with what i ahve observed about strat's and nortript's different effects- nortrip semed more emotional, and not in an anesthetic way, it heightens tham actually <for me>. strat seemed more alerting somehow, and i moved up quickly in my workplace than landed a new job not long afeter starting it. thoughts?
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.
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).
Posted by harryp on May 9, 2004, at 1:46:56
In reply to Re: ok, here's what my pdoc said » Questionmark, posted by zeugma on May 8, 2004, at 20:35:04
Have you tried desipramine? My literature indicates it's the least sedating TCA, and has a very powerful norepinephrine effect.
You could probably replace the TCA, SSRI, and the Strattera with Parnate and get a much better SE profile. It is a remarkable drug for vegetative depression and anxiety. The diet requires care, and you should make arrangements with a local doctor and ER to have your chart and phentolamine availiable in the event you have a hypertensive rxn. (Not something to be paranoid over--just requires prompt treatment).
Posted by Questionmark on May 9, 2004, at 2:54:12
In reply to Re: ok, here's what my pdoc said » Questionmark, posted by zeugma on May 8, 2004, at 20:35:04
> <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).
>
Okay, let's see. First of all, i think harryp's idea with the Parnate could be good, except that it's often not very good for anxiety, and can sometimes be downright terrible for it. Maybe Parnate plus Klonopin would be a good combination though (which is something i've always been curious to try, since the Parn would help negate the Klon's negative effects on cognition and mood, and the Klon would counter Parnate's anxiogenic and overemotional effects.) Actually, since you have such anergic, anhedonic depression (suggesting inhibited transmission of NE, DA, or both), then i wonder if your anxiety is related to low catecholamine transmission as well (of course, it's possible they could be low in some areas and high or normal in others-- i have no idea). If this is the case, then maybe something like Parnate WOULD be quite beneficial for you. Just a thought.Good points about the depressiogenic effects of Klonopin and the greater sedative effects of clomipramine (compared to nortriptyline). i'm guessing that the clomip. and the nortrip. are relatively similar in regards to anticholinergic potency. And the clomip. is more sedative due to its H1 antagonistic (or antihistaminic) effects. So if you don't already know, find out how you react and deal with antihistamine effects (maybe buy some benadryl/diphenhydramine?) Some people like it; some people can't stand it (anti-H1 effects that is). That should help you decide about the clomipramine. Also take note that (though you're probably already aware) clomipramine is extremely serotonergic (very potent 5-ht reuptake inhibitor). As far as adverse reactions with other drugs go, just try to find out the liver enzymes affected by any drugs you think you may take in the near future and compare this with those inhibited by clomipramine. If none of the enzymes are the same (or none are strongly inhibited), then you should have nothing to worry about. One thing you should realize though is that i think if you smoke this will significantly increase the concentrations of either clomipramine or its metabolite imipramine, or both (can't remember-- i think will just up the clomipramine).
Lexapro might be quite good for your anxiety but it probably won't be good at all for the type of depression you have (just my guess). But maybe with a noradrenergic drug like nortriptyline or Strattera it would be useful. It also should have less side effects than clomipramine would. Oh, and as harryp also mentioned, desipramine might really be worth looking into. For some reason i see desipramine as being better than Strattera, though similar. i'm not sure why, i just have a poor image of Strattera (mostly from alot of anecdotes i think), though maybe it's inaccurate. Alot depends on how much serotonin stimulation you think you need, among other things of course. If little to none, then clomipramine and Lexapro are not even worth considering.
Yeah, i think you should find the right, good, effective antidepressant drug or combination, and then when you have satisfactorily established that, then gradually add in Klonopin until your anxiety is under control as well.
Sounds promising. Good luck.
Posted by zeugma on May 9, 2004, at 4:09:33
In reply to Re: ok, here's what my pdoc said, posted by harryp on May 9, 2004, at 1:46:56
> Have you tried desipramine? My literature indicates it's the least sedating TCA, and has a very powerful norepinephrine effect.
I brought this up to my dr. it was actually the first thing out of my mouth when I sat down there- 'what about replacing Pamelor and Strattera with Norpramin?' He claimed that nortriptyline and desipramine were, from his point of view, virtually interchangeable, except that he claimed he saw less side effects on nortriptyline, because a lower dose was required to obtain an effect. This was how we got talking about the brainstem vs. frontal lobe sites of action, because he thought the secondary amine TCA's worked mainly in the brainstem while strattera worked in the frontal lobes- hence its greater efficacy in ADD. We argued about this for a while, because i have seen no evidence that indicates that Strattera is more effective than desipramine for ADD. He claimed to be doubtful about this, and that he didn't know why desipramine was so effective for ADD if it worked more in the lower brain, and that he wasn't sure that the two drugs had the same effect on ADD despite the studies. My ignorance on this caused me to insert a question mark on this point in an earlier post. Several thoughts:
Strattera does have a distinctly different effect on ADD than nortriptyline. Over the last year I've attributed it mainly to Strattera's lack of a sedating effect, leading to greater mental clarity. I suppose it could also be attributed to a slight difference in where the drug's action falls, or for all I know it could be a pure placebo effect.
Two years ago before strattera came out, he had mentioned the drug to me as a promising one to try if nortriptyline didn't reverse all my symptoms. He said "the two drugs go very well together." It's apparent from what he said the other day that he was referring to this localization effect, and I don't know if this is something the Lilly people are pushing, or if there is evidence out there that I haven't seen. I am a natural skeptic, but he doesn't seem like the type of pdoc to fall for the latest marketing hype. He's kept me on a TCA for two years, despite protests from me at tmes, and no one's marketed nortriptyline since the Stone age.
>
> You could probably replace the TCA, SSRI, and the Strattera with Parnate and get a much better SE profile. It is a remarkable drug for vegetative depression and anxiety. The diet requires care, and you should make arrangements with a local doctor and ER to have your chart and phentolamine availiable in the event you have a hypertensive rxn. (Not something to be paranoid over--just requires prompt treatment).And I bet parnate would be great for ADD because of its dopaminergic and noradrenergic effects. It's something I've definitely considered. <See my comments too below.>
>
Posted by zeugma on May 9, 2004, at 5:04:05
In reply to Re: ok, here's what my pdoc said » zeugma, posted by Questionmark on May 9, 2004, at 2:54:12
> > <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).
> >
>
>
> Okay, let's see. First of all, i think harryp's idea with the Parnate could be good, except that it's often not very good for anxiety, and can sometimes be downright terrible for it. Maybe Parnate plus Klonopin would be a good combination though (which is something i've always been curious to try, since the Parn would help negate the Klon's negative effects on cognition and mood, and the Klon would counter Parnate's anxiogenic and overemotional effects.) Actually, since you have such anergic, anhedonic depression (suggesting inhibited transmission of NE, DA, or both), then i wonder if your anxiety is related to low catecholamine transmission as well (of course, it's possible they could be low in some areas and high or normal in others-- i have no idea). If this is the case, then maybe something like Parnate WOULD be quite beneficial for you. Just a thought.Since I do have ADD, and a nasty, shape-changing form- extremely hyperactive when a child, becoming more and more inattentive in adolescence until by the time I was an adult I was literally swimming in 'brain fog'- it suggests poor NE and DA neurotransmission (all theorists agree that ADD/ADHD is liked to dopaminergic abnormalities, some pin it on the dopamine transporter's being overexpressed, some on the enzymatic catabolic processes - COMT and MAO-B- some on problems with the DA receptors themselves, etc.) Further evidence is the fact that I have many narcoleptic symptoms- EDS, which I've always had, and a nasty form of sleep paralysis, which i have not seen described in the way that i experience it, anywhere. It's commonly known that sleep paralysis produces hypnagogic hallucinations that tend to be terrifying to the dreamer, but I experience actual pain, shooting through my head, limbs, and feeling like electrical shocks. All the while the dream-content is usually of myself having a seizure- once, I told myself, that I would call 911 when I woke up, because i was having either a stroke or a grand mal seizure in my sleep! On waking, the pain generally subsides, but I usually feel both shaken and have a residual headache, and sometimes I've had whole series of these events- each time i would fall asleep, this thing would happen, each episode lasting at most three minutes after falling asleep (I keep two clocks across from my bed, and have for years, since I've had so much difficulty waking up, and that's been another factor in my checkered job and academic history.)
Anyway, this is a lot more than anyone would want to know about my sleep paralysis (which, incidentally, began at 23- typical age of onset for narcoleptic symptoms). Now, Hobson attributes both sleep paralysis, and narcolepsy in general, to cholinergic (I assume he means muscarinic) overactivity and corresponding weakness of the aminergic systems which hold REM in check, particicularly norepinephrine. He cites the example of a female patient of his, who suffered hypnagogic (hallucinations upon falling asleep) and hypnopompic (hallucinations that persist on waking) disruptions when she lowered her dose of amitriptyline, which is strongly anti-muscarinic as well as being pro-NE.
Hobson says that much less is known about the role of DA in REM. But if we put the severe ADD (associated with abnormalities of DA transmission) next to the tendency to go into REM on sleeping (associated with poor NE transmission combined, or caused by, a hyper-cholinergic state) then you could see why melancholic depression, anhedonia, and a vegetative state would eventually result! And theoretically, of course, Hobson's patient would have done just as well if not better on Parnate than amitriptyline.
>
> Good points about the depressiogenic effects of Klonopin and the greater sedative effects of clomipramine (compared to nortriptyline). i'm guessing that the clomip. and the nortrip. are relatively similar in regards to anticholinergic potency. And the clomip. is more sedative due to its H1 antagonistic (or antihistaminic) effects. So if you don't already know, find out how you react and deal with antihistamine effects (maybe buy some benadryl/diphenhydramine?) Some people like it; some people can't stand it (anti-H1 effects that is). That should help you decide about the clomipramine. Also take note that (though you're probably already aware) clomipramine is extremely serotonergic (very potent 5-ht reuptake inhibitor). As far as adverse reactions with other drugs go, just try to find out the liver enzymes affected by any drugs you think you may take in the near future and compare this with those inhibited by clomipramine. If none of the enzymes are the same (or none are strongly inhibited), then you should have nothing to worry about. One thing you should realize though is that i think if you smoke this will significantly increase the concentrations of either clomipramine or its metabolite imipramine, or both (can't remember-- i think will just up the clomipramine).I don't smoke. I find H-1 antagonism to be good for sleep, but at the same time I've been fatigued, and now that I've taken down the nortriptyline I'm not sleeping at all. Even drugs that aren't directly anticholinergic (like MAOI's and Strattera) have anticholinergic-like s/e due to NE potentiation. (Reminds me- I've got to put my sugarless sucking candy in my mouth that my dentist urged me to buy after discovering the cavity-filled desert that orifice has become. I am having emergency root canal next week so- anyway, I suspect I will have "anti-cholinergic" effects from Strattera even if I come off the TCA's entirely.)
> Lexapro might be quite good for your anxiety but it probably won't be good at all for the type of depression you have (just my guess). But maybe with a noradrenergic drug like nortriptyline or Strattera it would be useful. It also should have less side effects than clomipramine would. Oh, and as harryp also mentioned, desipramine might really be worth looking into. For some reason i see desipramine as being better than Strattera, though similar. i'm not sure why, i just have a poor image of Strattera (mostly from alot of anecdotes i think), though maybe it's inaccurate. Alot depends on how much serotonin stimulation you think you need, among other things of course. If little to none, then clomipramine and Lexapro are not even worth considering.
> Yeah, i think you should find the right, good, effective antidepressant drug or combination, and then when you have satisfactorily established that, then gradually add in Klonopin until your anxiety is under control as well.
> Sounds promising. Good luck.I don't know about serotonin. I agree that lexapro would be useless in this kind of vegetative depression by itself, but like you say, combined with TCA or Strattera might be a different story. I've never had a satisfactory trial with an SE drug. That isn't necessarily conclusive evidence that Lex wouldn't help, because in the past I was trying monotherapy with SSRI's. My great fear was that Lexapro would worsen the insomnia that could result from lowering the TCA. Already, down from 75 to 50 mg of nortrip, I'm having that 'early-morning awakening' that could get really tedious after a while. That could be the depression, of course, although I was sleeping ok until this weekend.
I think, since I'm on so much right now, and also I think the time to do a total drug washout will be when the school year ends (I'm a teacher) I'm going to slowly move the pieces around that are already on the board, as my pdoc wants to do. I'm calling him on Monday or Tuesday to report on the effects of the lowered nortrip. I have Klonopin on hand, and a fresh script, so if my anxiety skyrockets when the weekend's over- I'll try 1 mg (the stuff is very sedating, so I don't want to knock myself out more than necessary, and I would prefer using Benadryl for sleep than Klonopin). I prefer clomipramine to Lexapro, but that shouldn't be a problem in terms of calling in a script.
I appreciate both of your insights, you have given me a lot to think about.
This is the end of the thread.
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