![[dr. bob]](/dr-bob-sm.gif)
Dr. Bob is Robert Hsiung, MD,
bob@dr-bob.orgShown: posts 7 to 31 of 77. Go back in thread:
Posted by torachan on May 27, 2008, at 22:14:18
In reply to Re: The best Tricyclic for anxiety...., posted by linkadge on May 27, 2008, at 20:48:11
> Well one theory suggests that serotonergic medications can actually increase certain forms of anxiety via stimulation of certain serotonin receptors.
>
> Stimulation of the central 5-ht2a/c 5-ht3 receptors can cause anxiety.
>
> Peripherially, stimulation of 5-ht3 receptors in the stomach can cause nausia.
>
> Atypical antipsychotics are sometimes used to mitigate these side effects. Zyprexa/seroquel blocks 5-ht2a/c and 5-ht3, Risperidal blocsk 5-ht2c etc. Remeron also blocks 5-ht2a/c and 5-ht3 receptors and is somtimes used to reduce the side effecs of SSRI's.
>
> Imirpamine is a TCA but is somewhat like effexor in that it doesn't block any serotonin receptors. By blocking the reuptake of serotonin it increases serotonin signalling at every serotonin receptor in the body. Other TCA's like doxapin, trimipramine, amitryptaline clomipramine etc, block certain serotonin receptors which can sometimes result in a more comprehensive antianxiety effect.
>
> 5-ht2a blockade can improve sleep. 5-ht2c blockade can reduce psychomotor agitation. 5-ht3 blockade can reduce nausia (peripherially) and anxiety centraly.
>
> So I guess the bottom line is that if imipramine made anxiety worse another TCA may act differently.
>
> Linakdge
>
>
>
>Link, so if I understand you correctly, blocking of the 5HT2a/c receptors and 5HT3 receptor in a general way helps with anxiety because it reduces serotonin signalling at these sites. And you say amitryptiline and doxepin are the TCA's which have these effects most prominently. You are also indicating that Seroquel and Remeron both have these effects as well. Am I correct so far? Hope so.
So, with my incredible deductive skills--sarcasm--, since I tried Remeron unsuccessfully for a lengthy trial for my "anxiety" whether its GAD related, existentially related, whatever, and am currently trying Seroquel, in a way, without feeling better so to speak, these TCA's you mention as efficacious for anxiety would be 'duds' for me, since their action closely mimics that of Rem/Seroquel?
Just to give you perspective, my condition arose in the from of panic attacks in 1994 and have been on clonazepam ever since, with the odd SSRI experiment here and there, and a long mildly successful experience with Effexor. Once I was put on clonazepam, the PA's ended abruptly; they're certainly good for that.
By the way, what's your fee? ;)
Posted by Phillipa on May 28, 2008, at 0:14:34
In reply to Re: The best Tricyclic for anxiety.... » linkadge, posted by torachan on May 27, 2008, at 22:14:18
If pamelor is imipramine it plastered me to the bed til 2pm couldn't wake up and that was at only l0mg. Took it only once. Phillipa
Posted by linkadge on May 28, 2008, at 7:13:11
In reply to Re: The best Tricyclic for anxiety.... » linkadge, posted by torachan on May 27, 2008, at 22:14:18
>Just to give you perspective, my condition arose >in the from of panic attacks in 1994 and have >been on clonazepam ever since, with the odd SSRI >experiment here and there, and a long mildly >successful experience with Effexor. Once I was >put on clonazepam, the PA's ended abruptly; >they're certainly good for that.
Well, anxiety disorders can be of multiple biochemical origins. A 'serotonergic' anxiety disorder would probably benifit from maximal agonism of 5-ht1a in ratio to 5-ht2a/c or 5-ht3 etc. Serotonergic anxiolytics usually do not exert their full effect immediately (if they are going to work). Their delayed effect may be due to some form of neuroadaptive process or neurotrophic effect. You may benifit from a drug with strong serotonergic effect in combination with some form of receptor blocker.
Although mirtazapine does block 'bad' serotonin receptors it doesn't really have a strong serotonin boosting effect. Also noradrenergic medications like remeron, effexor desipramine can sometimes make anxiety worse.
A few things to mention.
You cannot quickly substitue an AD like remeron for a strong benzodiazapine like clonazepam since you will experience immedate withdrawl from clonazepam and little antianxiety effect from the AD.
You may want to try buspar (it doesn't work for everybody but it really helps some).
It helps to get very specific about the symptoms of anxiety you experience. Ie predominantly physical, mental, anticipatory, etc, since sometimes it give clues to which meds might help.
Finally, not everybody has a disorder responsive to serotonergic manipulation. Some people have a 'gabaergic mood' disorder. Other possibilites are:
endocannabanoid deficiancy
CNS neuropeptide imbalance
glutamate excess
overmethylation
thyroid issues
hypernoradrenergic states
excess cholinergic function
insufficiant cholinergic function
excessive 5-ht firing in dorsal raphai (ie if nicotine calms you down).
prefronal hypometabolism (if stimulants calm you down).
elevate PKC (mood stabilizers calm you down).etc.
Posted by jms600 on May 28, 2008, at 9:31:55
In reply to Re: The best Tricyclic for anxiety...., posted by linkadge on May 27, 2008, at 19:37:13
> I would think doxapin, elavil or clomipramine would be better than imipramine for GAD. These two have antagonist effect at 5-ht2a/c, 5-ht3 which imipramine does not have. I think imipramine is the most studied in this regard but that does not necessarily equate to efficacy.
>
> If sleep disturbance and/or GI problems are prominant, this might be another reason to choose elavil or doxapin which have antihistamine effects too.
>
>
> Linkadge
Linkadge,You said that "These two have antagonist effect at 5-ht2a/c, 5-ht3" Which two were you referring to; Doxapin, Elavil or Clomipramine??
Surely Clomipramine must have some sort of antagonist effect at 5-ht2a/c and 5-ht3 due to it's anxiolytic effects??
Thanks
jms
Posted by torachan on May 28, 2008, at 19:24:10
In reply to Re: The best Tricyclic for anxiety...., posted by linkadge on May 28, 2008, at 7:13:11
Honestly, I feel that my anxiety is largely just an inborn trait that I've had since a childhood, and the added stress of adulthood, plus the fact I was abusing drugs, caused the underlying disorder to manifest itself, so I would say it's mostly physical in origin.
Currently I'm trying Effexor and Remeron, but you said Effexor may exacerbate anxiety symptoms, I assume due to the noradrenergic effect, but doesn't Effexor only affect norepinephrine at around 225 mg? And you said a serotonin agonist would go well with a serotonin blocker, so perhaps Effexor at around 75-150mgs with Remeron at say 15-30mgs may be a good combo for anxiety?
Posted by SLS on May 28, 2008, at 19:42:29
In reply to Re: The best Tricyclic for anxiety.... » linkadge, posted by torachan on May 28, 2008, at 19:24:10
> Honestly, I feel that my anxiety is largely just an inborn trait that I've had since a childhood, and the added stress of adulthood, plus the fact I was abusing drugs, caused the underlying disorder to manifest itself, so I would say it's mostly physical in origin.
>
> Currently I'm trying Effexor and Remeron, but you said Effexor may exacerbate anxiety symptoms,In my opinion, it is sometimes smarter to act dumb and not try to figure out what a drug is going to do based upon some of the simplistic theories we come up with here, including my own. Effexor is effective when treating generalized anxiety disorder (GAD). That's what you should focus on. It works better than the SSRIs, including Paxil.
Take some time to look over the literature on the Web regarding Effexor and GAD. At this point in time, I think empirical observation must take precedence over prediction based on theory.
What is the rationale for using Remeron in combination with Effexor?
I would not give up on Effexor until you reach 300mg.
Good luck, whatever you choose to do.
- Scott
Posted by torachan on May 28, 2008, at 19:58:02
In reply to Re: The best Tricyclic for anxiety...., posted by SLS on May 28, 2008, at 19:42:29
Thanks Scott. Well the Remeron is what I was initially on after dropping Effexor and finding out that I do need an AD with my benzo for anxiety, or if I'm going to attempt to drop the benzo which ultimately is my goal. I've decided now that Effexor really did help with anxiety, and I'm thinking of keeping the Remeron for sleep, as I noticed with Effexor sleep tends to be disturbed.
You say up to 300mgs? I've read that around 225 mgs the norepinephrine effect kicks in which is detrimental for anxiety. I believe the highest I've ever went was 150mgs. And with that dose I was almost able to free myself from the benzo grip.
Anyways, I'll consider going up depending on how I feel. Incidentally, do you feel an SNRI like Effexor is better for anxiety, generally speaking, than any tricyclic available?
Posted by linkadge on May 28, 2008, at 20:04:17
In reply to Linkadge - which 2 anti-depressants??, posted by jms600 on May 28, 2008, at 9:31:55
>Linkadge,
>You said that "These two have antagonist effect >at 5-ht2a/c, 5-ht3" Which two were you referring >to; Doxapin, Elavil or Clomipramine??
Sorry, that was not clear. All three are fairly potent 5-ht2a/c and 5-ht3 antagonists.
Clomipramine is also a moderate dopamine d1/d2/d3 antagonist, which makes it like a SSRI / AP combo.
Amitriptyline is less potent a dopamine antagonist but more potent a 5-ht2a/c antagonist.
I could not find entries on doxapin's dopamine antagonism (if any).
I was a little incorrect about imipramine, it does have *some* affinity for 5-ht2a/c but according to to PDSP database, doxapin and amitryptaline are much stronger relative 5-ht antagonists.
The following were averaged from the PDSP database.Note:
***lower numbers indicate a higher affinity***
--------Doxapin-----Amitryptaline----Imipramine
5-ht----130------------30-------------11
NET----29-------------20-------------60
5-ht2a--25-------------4--------------120
5-ht2c--9--------------6--------------120
d1------no entry-------81-------------negligable
d2------no entry-------500------------500
d3------no entry-------no entry-------300So in comaprison to imipramine, amityrptaline and doxapin are somewhat relatively more potent 5-ht antagonists.
Linkadge
Posted by linkadge on May 28, 2008, at 20:15:39
In reply to Re: The best Tricyclic for anxiety.... » linkadge, posted by torachan on May 28, 2008, at 19:24:10
>I assume due to the noradrenergic effect, but >doesn't Effexor only affect norepinephrine at >around 225 mg? And you said a serotonin agonist >would go well with a serotonin blocker, so >perhaps Effexor at around 75-150mgs with Remeron >at say 15-30mgs may be a good combo for anxiety?
Yes and no. Some people say that remeron reduces the anxiogenic effect effexor but it may increase it via a different mechanism.
Remeron increase norepinephrine release via a mechanism destinct of that of effexor. The combination has been called "California Rocket Fuel". It can apparently be very stimulating in high doses.
I did not do well on remeron plus effexor (major high blood pressure and anxiety) but did very well on a citalopram / remeron combination.
In this case, the 5-ht antagonism may reduce certain forms of anxiety, but the added NE effect may cause a different form of anxiety.
Effexor may do well in combination with low dose trimipramine, doxapin, or amitryptaline.
Some people do well with effexor and low dose seroquel.
There is some evidence that the combination works synergistically to reduce the neurological effects of chronic stress.
see:
I used cyproheptadine in combination with effexor with sucess. I don't know if you can get your hands on cyproheptadine.
Linkadge
Posted by linkadge on May 28, 2008, at 20:30:34
In reply to Re: The best Tricyclic for anxiety...., posted by SLS on May 28, 2008, at 19:42:29
>Effexor is effective when treating generalized >anxiety disorder (GAD). That's what you should >focus on. It works better than the SSRIs, >including Paxil.
Yes and no. Wyeth did a number of head to head trials that favored their drug, but some of the SSRI companies fired back with trials that supported their drug. The SSRIs also appear to be more tollerable than venlafaxine.
>Take some time to look over the literature on >the Web regarding Effexor and GAD. At this point >in time, I think empirical observation must take >precedence over prediction based on theory.
But the "empirical" evidence is a little flawed.
I think if an indivudal is not gaining adequate relief with venlafaxine alone then it is not unreasonable to suggest something to augment it. There is good evidence that AP's can augment uptake inhibitors. Looking to drug mechanisms is may not work all the time, but the combination of a uptake inhibitor with some form of 5-ht receptor blocker does appear to have supporting literature in both human and animal models of anxiety.
>What is the rationale for using Remeron in >combination with Effexor?
I would not recomend this combination on account of significant noradrenergic stimulation.
>I would not give up on Effexor until you reach >300mg.
I would. Especially if you are experiencing unhealthy side effects like BP increase or a significant increase in anxiety.
I didn't sleep much at all on 150mg of effexor. I felt much better when I lowered it to 75mg and added 25mg of seroquel. I was also feeling much more suicidal as we went up on effexor. Effexor also causes dose dependant increases in cortisol (again probably a 5-ht2 related mechanism). 5-ht2 antagonists are strong anticortisol agents.
Doxapine, amitrpytaline, remeron, cyproheptadine, trimipramine, seroquel, risperidal, zyprexa and many more 5-ht2 antagonits have documented anticortisol effects. In contrast most pure uptake inhibitors (ie SSRI's etc) increase cortisol, sometimes even after prolonged adminstration. They may also ameliorate disrupted sleep profiles.
Many of the above 5-ht2 antagonists also increase slow wave sleep (a stage of sleep often lacking in depression). There is good evidence of this. If sleep is significantly disturbed sometimes a low dose of a 5-ht2 blocking drug would be very helpful.
Linkadge
Posted by SLS on May 28, 2008, at 20:32:24
In reply to Re: The best Tricyclic for anxiety.... » SLS, posted by torachan on May 28, 2008, at 19:58:02
> Thanks Scott. Well the Remeron is what I was initially on after dropping Effexor and finding out that I do need an AD with my benzo for anxiety, or if I'm going to attempt to drop the benzo which ultimately is my goal. I've decided now that Effexor really did help with anxiety, and I'm thinking of keeping the Remeron for sleep, as I noticed with Effexor sleep tends to be disturbed.
>
> You say up to 300mgs? I've read that around 225 mgs the norepinephrine effect kicks in which is detrimental for anxiety. I believe the highest I've ever went was 150mgs. And with that dose I was almost able to free myself from the benzo grip.
>
> Anyways, I'll consider going up depending on how I feel. Incidentally, do you feel an SNRI like Effexor is better for anxiety, generally speaking, than any tricyclic available?It depends on the disorder being treated. Agoraphobia and panic disorder might be particularly treatable with imipramine.
I could not come up with any investigative comparisons between Effexor and Paxil that demonstrated a clear advantage to either drug when treating GAD. As of now, Zoloft, Paxil, Lexapro, and Effexor are considered to be equipotent treatment alternatives. You always have Nardil to fall back on if all else fails. I have personally seen this drug work remarkably well for GAD and SAD as well as depression. Nardil is also touted as having efficacy when treating OCD.
It seems that the various anxiety disorders respond differentially to specific antidepressants. Effexor might not be worth trying if social anxiety disorder (SAD) is the illness being treated. Here, the potentiation of NE might account for this. So, here we have two different anxiety disorders (GAD versus SAD) responding best to different antidepressants. Paxil seems to be better than Effexor when treating SAD. Effexor might even exacerbate SAD.
You would know better than I whether or not increasing the dosage beyond 225mg is any more effective when treating GAD. However, 300mg seems to be a magic number with Effexor when treating depression.
So, I would say that for GAD, the SSRIs and Effexor are better than the tricyclics.
The more they refine the definitions of the anxiety disorders and their symptom clusters, the more these disorders seem to be distinct in their responsivity to various antidepressants.
- Scott
Posted by linkadge on May 28, 2008, at 20:35:21
In reply to Re: The best Tricyclic for anxiety.... » SLS, posted by torachan on May 28, 2008, at 19:58:02
The idea that NET inhibiting drugs are good for anxiety is not really all that strightforward.
For some people the noradrenergic drugs greatly increase anxiety. For some forms of anxiety and panic they appear to help. There are probably a number of factors related to why this is.I am assuming that both low NE and elevated NE can lead to certain forms of anxiety. Just as Serotonin can be both anxiolytic and anxiogenic.
Listen to what the drug does for you and don't worry about what the drug is "approved to do".
Linkadge
Posted by linkadge on May 28, 2008, at 20:43:05
In reply to Re: The best Tricyclic for anxiety.... » torachan, posted by SLS on May 28, 2008, at 20:32:24
I wouldn't necessarily say that the SSRI's / venlafaxine are better for GAD than the TCA's.
There are a number of reasons why they are more *studied* in GAD, ie the proliferation of SSRI usage based on their presumed safety, the more recently shunned use of benzos for anxiety, and the increase in medicalization of lesser anxiety disorders in general.
For myself, I needed to be sent into a severly agitated state by SSRI's, labled bipolar, subsequently treated by AP's then finally tried on TCA's to realize that the SSRI's weren't all that great for my GAD and agitated depression.
Ironically, many people are being called bipolarish based on the efficacy of AP augmentation when the AP might just be helping via a serotonergic modulatory mechanism.
Linakdge
Posted by SLS on May 28, 2008, at 20:55:20
In reply to Re: The best Tricyclic for anxiety...., posted by linkadge on May 28, 2008, at 20:43:05
Black.
Posted by torachan on May 28, 2008, at 22:37:34
In reply to Re: The best Tricyclic for anxiety...., posted by linkadge on May 28, 2008, at 20:30:34
> >Effexor is effective when treating generalized >anxiety disorder (GAD). That's what you should >focus on. It works better than the SSRIs, >including Paxil.
>
> Yes and no. Wyeth did a number of head to head trials that favored their drug, but some of the SSRI companies fired back with trials that supported their drug. The SSRIs also appear to be more tollerable than venlafaxine.
>
> >Take some time to look over the literature on >the Web regarding Effexor and GAD. At this point >in time, I think empirical observation must take >precedence over prediction based on theory.
>
> But the "empirical" evidence is a little flawed.
>
> I think if an indivudal is not gaining adequate relief with venlafaxine alone then it is not unreasonable to suggest something to augment it. There is good evidence that AP's can augment uptake inhibitors. Looking to drug mechanisms is may not work all the time, but the combination of a uptake inhibitor with some form of 5-ht receptor blocker does appear to have supporting literature in both human and animal models of anxiety.
>
> >What is the rationale for using Remeron in >combination with Effexor?
>
> I would not recomend this combination on account of significant noradrenergic stimulation.
>
> >I would not give up on Effexor until you reach >300mg.
>
> I would. Especially if you are experiencing unhealthy side effects like BP increase or a significant increase in anxiety.
>
> I didn't sleep much at all on 150mg of effexor. I felt much better when I lowered it to 75mg and added 25mg of seroquel. I was also feeling much more suicidal as we went up on effexor. Effexor also causes dose dependant increases in cortisol (again probably a 5-ht2 related mechanism). 5-ht2 antagonists are strong anticortisol agents.
>
> Doxapine, amitrpytaline, remeron, cyproheptadine, trimipramine, seroquel, risperidal, zyprexa and many more 5-ht2 antagonits have documented anticortisol effects. In contrast most pure uptake inhibitors (ie SSRI's etc) increase cortisol, sometimes even after prolonged adminstration. They may also ameliorate disrupted sleep profiles.
>
> Many of the above 5-ht2 antagonists also increase slow wave sleep (a stage of sleep often lacking in depression). There is good evidence of this. If sleep is significantly disturbed sometimes a low dose of a 5-ht2 blocking drug would be very helpful.
>
>
> Linkadge
>
>
>
>Link, as I read in another one of your posts, you mentioned that the use of Effexor at 75 and Seroquel at 25 was good for your anxiety, correct. This is the drug combo my current doc is recommending, although he seems to be favoring a higher does of Seroquel. But I'm a bit confused here. You said that a 5HT2? blocker would be a good combination with Effexor, and you included in your list Remeron along with Seroquel, yet you said Effexor and Remeron would not be a good combo for anxiety due to excessive noradrenergic stimulation.
Wouldn't a low does of Remeron prevent the problem you speak of? With Seroquel and me, it's odd, because I don't seem to have the effects which most people experience like a single 25mg dose "knocking them out". I once tested the "knockout strength" of this drug early in the trial by taking 350mgs and I was still on my feet, after being up all night, which Effexor gives me the tendency to do. Also, I feel a bit disorientated on Seroquel which scratches at my edginess, so I'm a little confused as to why if Remeron and Seroquel are both 5HT blockers, and with me at least Remeron being a far superior sleep inducing agent, why would you recommend against the Rem?
I don't expect you to diagnose me and dispense with medical advice, just a little informed opinion. I just seem to trust your opinion and advice, and will discuss your thoughts, which have become my thoughts, with my doctor.
Thanks sincerely.
Posted by SLS on May 29, 2008, at 5:16:03
In reply to Re: The best Tricyclic for anxiety.... » linkadge, posted by torachan on May 28, 2008, at 22:37:34
Hi.
I came upon a pretty convincing abstract on Medline demonstrating that, indeed, Linkadge and your doctor are right. There seemed to be no advantage to increasing the dosage beyond 75mg when treating generalized anxiety disorder (GAD).
What dosage of Seroquel is your doctor thinking of using?
- Scott
**************************************************1: Psychopharmacology (Berl). 2005 Jan;177(3):280-8. Epub 2004 Jul 16.Click here to read Links
Efficacy of low and higher dose extended-release venlafaxine in generalized social anxiety disorder: a 6-month randomized controlled trial.
Stein MB, Pollack MH, Bystritsky A, Kelsey JE, Mangano RM.Department of Psychiatry, University of California San Diego, 9500 Gilman Drive, La Jolla, CA 92093-0985, USA. mstein@ucsd.edu
RATIONALE: There is a need for new pharmacological treatments for generalized social anxiety disorder (GSAD), which is a common, often disabling condition. OBJECTIVE: To compare the efficacy and safety over 6 months duration of two dose ranges of venlafaxine extended-release (ER) with placebo in patients with GSAD. METHOD: Twenty-eight-week, double-blind, multi-center study in 386 adult outpatients with DSM-IV GSAD. Patients were randomized to placebo, venlafaxine ER fixed low dose (75 mg/day), or venlafaxine ER flexible higher dose (150-225 mg/day). Primary efficacy variable was change on the Liebowitz Social Anxiety Scale (LSAS). Secondary efficacy variables included, among others, the proportion of responders on the CGI Global Improvement Item (score 1 or 2), and the proportion of remitters (defined as an LSAS score of <or=30). RESULTS: Improvement on the LSAS was greater with venlafaxine ER (at 75 mg/day or 150-225 mg/day) than placebo, and was sustained throughout the 6-month trial. Of patients receiving venlafaxine ER (at any dose), 58% responded to treatment compared to 33% of those receiving placebo (P<0.001); corresponding remission rates were 31% and 16% (P<0.01). There were no differences in outcome according to venlafaxine ER dosage. CONCLUSIONS: Venlafaxine ER was effective in the treatment of GSAD. The comparable efficacy at low and higher doses may indicate that norepinephrine reuptake blockade does not contribute to therapeutic effect in GSAD. This hypothesis should be tested using agents with specific actions on norepinephrine reuptake blockade.
Posted by linkadge on May 29, 2008, at 7:58:11
In reply to Re: The best Tricyclic for anxiety.... » linkadge, posted by torachan on May 28, 2008, at 22:37:34
>This is the drug combo my current doc is >recommending, although he seems to be favoring a >higher does of Seroquel. But I'm a bit confused >here. You said that a 5HT2? blocker would be a >good combination with Effexor, and you included >in your list Remeron along with Seroquel, yet >you said Effexor and Remeron would not be a good >combo for anxiety due to excessive noradrenergic >stimulation.
>Wouldn't a low does of Remeron prevent the >problem you speak of? With Seroquel and me, it's >odd, because I don't seem to have the effects >which most people experience like a single 25mg >dose "knocking them out". I once tested >the "knockout strength" of this drug early in >the trial by taking 350mgs and I was still on my >feet, after being up all night, which Effexor >gives me the tendency to do. Also, I feel a bit >disorientated on Seroquel which scratches at my >edginess, so I'm a little confused as to why if >Remeron and Seroquel are both 5HT blockers, and >with me at least Remeron being a far superior >sleep inducing agent, why would you recommend >against the Rem?
Well, it all depends on how you personally react. Yes remeron is a 5-ht2 blocker but it also has strong effects as a noradrenergic autoreceptor antagonist. Basically, remeron increases the release of norepinephrine. If the dose is low enough this side effect may be negligable (but then too may be the 5-ht antagonist effect).
Some people find that the combination of remeron and effexor very stimulating. The remeron causes a release of norepinephrine and the effexor blocks the reuptake of it.
Its hard to know how you might react. Remeron really helped me sleep on its own, but caused stimulation when combined with effexor. I didn't get that stimulation when REM was combined with a non-noradrenergic drug.
Its not just that the two are noradrenergic, its that they are synergistically noradrenergic.
Nevertheless, if you are going to combine the two, I'd start with a low dose of remeron, (no more than 7.5 or 3.75 (1/4 of a 15mg tab).
>I don't expect you to diagnose me and dispense >with medical advice, just a little informed >opinion. I just seem to trust your opinion and >advice, and will discuss your thoughts, which >have become my thoughts, with my doctor.
I understand. I agree that its not always the best idea to choose drugs based on mechanism, but I have generally found drugs to behave in a manner consistent with what I understand about them.
Seroquel didn't knock me out. 25mg just facilitated sleep.
A number of doctors (especially old school doctors) will use low dose amitryptaline, or doxapin for sleep/anxiety augmentation which can be effective.
Linkadge
Posted by johnj on May 29, 2008, at 19:07:59
In reply to Re: The best Tricyclic for anxiety...., posted by linkadge on May 29, 2008, at 7:58:11
Linkade:
The docs where I am at don't seem to want to use low dose TCA's for sleep but I believe they may be very good drugs for augmentation like you suggest.
Remeron helped me sleep but cause a lot of physcial anixety as did seroquel (especially at 50 mg). Seroquel also made me wake up almost every hour. Do you have an idea what mechanism may cause this physical anxiety from REM and seroquel? Does this suggest that certain TCA's may be good or not good for me? I know drug trials tell the real story but I would appreciate your thoughts. It seemed any doses of REM did not help and anything over 15mg was really bad. REM also made it hard for me to let things go and increased irritability. I sure don't need that.
thank you.
johnj
Posted by torachan on May 29, 2008, at 19:35:05
In reply to Re: The best Tricyclic for anxiety.... » torachan, posted by SLS on May 29, 2008, at 5:16:03
Thanks Scott, I appreciate your input. The dose the doctor initially prescribed me at was 50 mg, but just as the above poster johnj mentioned, I found myself somewhat agitated the next day--I take it at night, as expected. I can't explain why the 50 mg dose would be aggravating to me.
I think I'll try out 25mgs for a while to discern the effects, and if all doesn't go well, I'll drop it like a hot potato and introduce the idea of trying a low dose TCA like doxepin or amitryptiline in combination with Effexor at 75. Or I'll go back to Remeron at 15 mg's.
Thanks.
Posted by johnj on May 29, 2008, at 20:14:33
In reply to Re: The best Tricyclic for anxiety.... » SLS, posted by torachan on May 29, 2008, at 19:35:05
For me the 50-mg dose caused akathisia. My pdoc knew right away what was going on becasue I had no clue just relayed the symptoms. Med sensitivity is a strange thing. I tried a few days at 50 but just couldn't take it as my legs were jumpy and I couldn't sit still. It was a horrible feeling. I hope a tca helps you as I am eyeing one myself. Regards
johnj
Posted by linkadge on May 30, 2008, at 8:20:30
In reply to Re: The best Tricyclic for anxiety.... » linkadge, posted by johnj on May 29, 2008, at 19:07:59
>Remeron helped me sleep but cause a lot of >physcial anixety as did seroquel (especially at >50 mg). Seroquel also made me wake up almost >every hour. Do you have an idea what mechanism >may cause this physical anxiety from REM and >seroquel?
Were you taking them alone? Its hard to say. Neither are pure 5-ht blockers. Some people don't do well with the alpha-2 adrenoreceptor blockade of mirtazapine (which ehnances norepiniephrine release). Not sure about the seroquel. Some people are very sensitive to dopamine blockade. Seroquel also has a metabolite which is a norepinephrine reuptake inhibitor. Its hard to say.
Seroquel affected my sleep in two ways. If I was very depressed it improved sleep considerably, but as I started to feel better I noticed that it made sleep very fragmented.
>Does this suggest that certain TCA's may be good >or not good for me? I know drug trials tell the >real story but I would appreciate your thoughts.
It is hard to say. They can be good augmenting agents and can help anxiety, but some people are sensitive to certain effects. They may help anxiety best when it is associated with some degree of depression. Nevertheless, elavil or trimipramine might make a good trial.
>It seemed any doses of REM did not help and >anything over 15mg was really bad. REM also made >it hard for me to let things go and increased >irritability. I sure don't need that.
This may be a sign that you are actually benifitting from some degree of 5-ht2a/c *agonsm*.
It gets a little complicated when OCD type problems are comorbid. While 5-ht2a/c blockers usually are good for depression augmentation, they can sometimes make obsessions worse. (Apparently 5-ht2a/c blockers reduce some of the antiOCD effects of serotonergic medications).
Remeron monotherapy can also cause irritability like you mentioned.Amitryptaline may be similar to remeron in some respects. A number of studies have shown however, that amitryptaline is superior as an AD. I'm not sure how it compares for anxiety.
You you mind me asking your main symptoms and the meds you've tried?
Linkadge
Posted by johnj on May 30, 2008, at 9:05:31
In reply to Re: The best Tricyclic for anxiety...., posted by linkadge on May 30, 2008, at 8:20:30
Linkadge:
Anxiety/OCD (pure O type). I originally had a panic attack while living abroad in 1992 and become depressed because I couldn't stop the panic. I eventually settled on pamelor/lithium/tranzene. I did good until 2001 when I got pneumonia and then things went to hell.
I developed allergies/immune system problems/exercise intolerance/med sensitivity/ and sleep issues again. I tried remeron a few times and then settled on 15 mg only because it helped me sleep. It sort of changed my personality and I didn't like what I became. It slowly increased OCD type symptoms, getting stuck on things and made me fantasize a lot. Very strange stuff. I then weaned off everything (paniful) and was med free for 9 months but had anxiety and sleep issues. I finally caved and tried paxil, luvox, klonopin, and xanax. I went downhill on these meds with the ssri's causing internal anxiety. Out of desperation I went back to 15 mg remeron but this made me very angry/depressed so I lasted 6 months. I have been off meds for 10 months but the anxiety waxess and wanes and sleep can be horrible at times. It doesn't seem to follow a pattern either. Last night I slept 3.5 hours and couldn't get back to sleep so I took Chlorpheniramine and got two more hours of sleep. Anxiety and worry are my biggest issues along with sleep. My anxiety is very physical in nature.
My counselor thinks there is some background depression too. He also wondered since I became med sensitive after the pneumonia that maybe just cutting down my dosages might have worked. I felt like all I had was side effects from the meds after getting sick. I usually fall asleep easy and then wake up after a few hours and am up and down. It seems I wake up after dreaming for some time. I don't remember dreaming for the first few hours I sleep. After the pnuemonia my sleep has never been good. I don't get the nodding off feeling like I used too. The suspected bipolar at one point but mood stablilizers were not good and neurontin was terrible. I really need something to take the edge off and allow me to get quality sleep as that is the key for me. My sleep patterns are definately not nearly the same they used to be, the pneumonia really wacked out by body and mind. Sorry for the long response.
Thanksjohnj
Posted by torachan on May 30, 2008, at 14:10:13
In reply to Re: The best Tricyclic for anxiety.... » linkadge, posted by johnj on May 30, 2008, at 9:05:31
Johnj, your situation sounds very similar to mine, along with the fact my name is John, and panic attacks struck around 1993. The difference however is I've been on clonazepam ever since, which stopped the panic attacks dead in its tracks, but the underlying problem manifested as GAD as I suspect happens alot. I also have sleep issues, and although Effexor seems to help with my mood and a little with my anxiety, judging by the fact that I'm able to reduce mt benzo dosage when on Effexor, this drug seems to disrupt sleep quite considerably. Actually, benzos in long term use begin to act as sleep disrupters as well. I also slept maybe 3-4 hours last night. I seem to wake up and my mind ruminates on basically nothing in particular and I can't get back to sleep. Sometimes I don't even feel like I'm sleeping at all.
I also feel my anxiety is physical in nature. I tried to get my doctor to test my blood cortisol levels and glucoadrenocorticoid levels--fancy term which means the hormone that regulates the release of adrenaline controlled by the pituitary gland. He said a drug to reduce these levels would not reduce my anxiety, even if it was physical. I could not understand this, but upon further reflection it seems to make some sense. I though if these drugs are not working in reducing my overall anxiety, why not reduce the results of anxiety ie; stress induced physiological effects.
Anyways, sleep is always an issue when treating anxiety as I can attest. Like I said, benzos lose there sedating properties over time and SSRI/NRI's seems to disrupt sleep.
John
Posted by johnj on May 30, 2008, at 16:32:15
In reply to Re: The best Tricyclic for anxiety.... » johnj, posted by torachan on May 30, 2008, at 14:10:13
John:
Yes, sounds very similiar indeed. I couldn't take klonopin as it depressed me and caused rebound anxiety. It is strange in that I need something to help sleep but not with a terrible hangover the next day.
I have looked at doxepin, pamelor, elavil, and trimimpramine as possiblities. I wonder if they may work with effexor for you? I have thought of effexor but I don't need anything that would disrupt sleep unless I take something that helps. Srri's are out.
It has been hard as I used to sleep ok even if I worried but now the sleep mechanism is screwed up. I suppose I will crash tonight. I hear you about the late night rumination stuff. Last night I slept through the storms only to wake AFTER they ended about 1 AM! Then I couldn't fall back asleep until I took an antihistamine. It seems my sleep pattern is off to a significant degree as I know I am not getting enought deep sleep.
I don't know but it seems to reason that if you reduce the physiological effects of stress over time your body would relax and sleep would improve. I think this would relax the mind in the long run but I am not sure. Keep me (us) informed on what you try and I will do the same.
regards
johnj
Posted by johnj on May 30, 2008, at 16:33:17
In reply to Re: The best Tricyclic for anxiety.... » johnj, posted by torachan on May 30, 2008, at 14:10:13
One more thing. Is your name Tora-chan as in Japanese?
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