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Dr. Bob is Robert Hsiung, MD,
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Posted by HelenInCalif on August 2, 2007, at 16:35:22
In Short:
I'm seeing my pdoc tomorrow to discuss my newly growing anxiety in reaction to recent life stresses. We're going to have a philosophical difference over the best way to treat it, based on an earlier short June consultation.How can I work through this disagreement? Have you seen a conflict between SSRIs vs. Klonopin for anxiety?
She'll suggest starting Celexa for anxiety. I'd rather take nothing than Celexa if I'm not depressed. The side-effects I get aren't worth it. Even the idea of starting a SSRI makes me feel anxious. Klonopin, on the other hand, worked for me. No SSRI did 5% of what Klonopin did for anxiety.
Question:
Is it possible for pdocs to prescribe Klonopin for an "As Needed" treatment? Is there a prescription level that *in her mind* is unlikely to lead to tolerance?(1)Note that I also take ritalin for ADD: I've taken it continously for 11 years and have never changed my dosage. That and the bcp are my only regular prescriptions.
Thanks,
Helen
-------------------------more details:
I've taken SSRIs several times long-term in the past 2 decades for depression: if they ever could have also helped me with anxiety, I should have seen it. I never did. Until Klonopin I never knew what "not feeling anxious in public speaking situations" felt like. Never.
I'd much rather take Klonopin a few times a week and only during anxiety-provoking events. This way I can continue to break the connection between "feeling anxious" and "public speaking" for example. I found that if I take Klonopin 3 times in a row for a type of event, then on the 4th time I barely feel that stress, because I've unlinked "stressful" from "event."
It seems like that's much more focused and efficient than taking an SSRI continuously, especially as I'm not feeling any depression.
SSRIs in my experience:
1. do help with depression, but don't help with my anxiety- else they would have in the past, and
2. don't stop the depression from starting, IF the depression is caused by anxiety.
3. have dreadful side effects- sex, drymouth, horrid headaches and more on withdrawal.Background / more on history:
In late June I was facing several stressful events: job loss, job interviews, public speaking. So by phone consult she prescribed a short (2 week) course of Klonopin, but suggests I should move to Celexa full time after tomorrow's appointment.I'd first (and last) had Klonopin in early 2004-early 2005, and Celexa in mid 2004-mid 2005.
The reason I started Klonopin in 2004 was to help with a big issue- a severely ill relative in the hospital for months before he died, plus two other relatives died that year. I'd started Celexa as well not long after because all that death got me depressed.
When I took Klonopin for the first time, it truly helped with anxiety- both at the hospital and for more ordinary life situations. I was able to do things like give a lecture without anxiety: I'd never done that before.
After early 2005 I didn't have more Klonopin, but I did save some last pills for "emergency" use: interviews, public speaking, etc. Even when I was still talking Celexa the Celexa didn't help with anxiety, not the way one Klonopin could.
-----------------------
(1) Quite frankly, I took Klonopin daily for months back in 2004 and didn't develop a tolerance, but that doesn't seem relevant to her or the HMO's guidelines.
Posted by linkadge on August 2, 2007, at 17:13:29
In reply to pdoc likes SSRI not Klonopin for anxiety: I don't., posted by HelenInCalif on August 2, 2007, at 16:35:22
I think your best bet is to lay down your case in as clear, calm and short a case as possable.
I think the doctors are more likely to turn off when they hear long stories or excessive reasoning.
I would start by stating that.You have taken several SSRI's and they have not helped anxiety.
You have taken benzodiazapines and they have helped.
You have no history of compuslive drug use.
You would like to try a benzodiazapine for anxiety, and that if you do happen to grow tollerant etc, you are willing to reasses this treatment option.
Linkadge
Posted by HelenInCalif on August 2, 2007, at 18:04:03
In reply to Re: pdoc likes SSRI not Klonopin for anxiety: I don't., posted by linkadge on August 2, 2007, at 17:13:29
Yes, when I'm talking with doctors I'm very careful to keep my statements short and sweet. I went into more details here because those details inform my history as to why I dislike SSRIs.
on my history:
Could the fact that I'm taking a schedule II med- ritalin- affect how they'd prescribe a schedule IV medicine?Back in 2005 I got a feeling that Kaiser HMO generally discourages use of Klonopin for anything but short term use. Instead, it seems like they think of SSRIs for anxiety as a one-size-fits-all solution.
Which strikes me as a too-general a rule if it's true. i.e. that they'd rather have patients face the real side effects of a SSRI than deal with the possibility of a patient getting tolerant or addicted to Klonopin in the future.
Maybe Klonopin requires too many followup visits as compared to an SSRI, and that discourages the former's use.
As said, I felt the side effects of Celexa and every earlier SSRI I've had strongly: the only reason those effects were tolerable was because depression was worse. Weight gain, dry mouth, totally lost sex, and nasty pains if I didn't stop slowly-- plus weird side-effects for the first few weeks like tremors- my hands would shake. Extra shakes during a job interview? That isn't helpful.
But for my anxiety of right now, I don't have weeks to wait nor do I have time to put up with the other side effects... which, for Celexa, seems to include anxiety itself!
Posted by linkadge on August 2, 2007, at 18:51:38
In reply to I wonder about Kaiser. (pdoc + SSRIs for anxiety), posted by HelenInCalif on August 2, 2007, at 18:04:03
It doesn't make a lot of sence. I suppose one could outright ask a doctor for a explaination of their logic.
It really makes no sense, and as the truth about SSRI side effects and withdrawl becomes more apparent I think that doctors arguments look all the more flimsy.
I mean SSRI's can poop out and cause nasty withdrawl too, so what gives?
Some of them aren't really much of free thinkers.
Linkadge
Posted by Phillipa on August 2, 2007, at 22:25:18
In reply to Re: I wonder about Kaiser. (pdoc + SSRIs for anxiety), posted by linkadge on August 2, 2007, at 18:51:38
I agree fully with both of you. I am a 35year user of benzos and no I haven't increased doses over the years. Acturally I take less. And the ad's don't lessen anxiety for me they make it worse. If need be pay out of pocket for a benzo friendly doc they are all over. What state are you in? Love Phillipa
Posted by Bonnie_CA on August 3, 2007, at 1:55:34
In reply to I wonder about Kaiser. (pdoc + SSRIs for anxiety), posted by HelenInCalif on August 2, 2007, at 18:04:03
>
> Back in 2005 I got a feeling that Kaiser HMO generally discourages use of Klonopin for anything but short term use. Instead, it seems like they think of SSRIs for anxiety as a one-size-fits-all solution.
Kaiser treats all mental illness like a one-size-fits-all... their solution to everything is group sessions and whatever drug is hot on the market. We're all just on their assembly line, bring 'em in, ask a couple questions, and send them away with a medication. Don't bother them furthur. Just take your drugs. If the drug isn't working, it must be something you're doing wrong. Seriously. This is what I got when I was there. Never again. Got rid of them in January, and since have gotten competent help and have improved a lot.
>
> Which strikes me as a too-general a rule if it's true. i.e. that they'd rather have patients face the real side effects of a SSRI than deal with the possibility of a patient getting tolerant or addicted to Klonopin in the future.
>But see, they still lie about the side effects. Ok, maybe they've stopped lying about the common side effects, but they still lie about the withdrawal. I wish doctors would quit getting so bent out of shape over benzos. I haven't really seen a better class of drugs for anxiety. They keep trying by putting it on another label, but I'm not convinced.
-Bonnie
Posted by BGB on August 3, 2007, at 7:01:09
In reply to Re: I wonder about Kaiser. (pdoc + SSRIs for anxiety), posted by Bonnie_CA on August 3, 2007, at 1:55:34
>
> >
> > Back in 2005 I got a feeling that Kaiser HMO generally discourages use of Klonopin for anything but short term use. Instead, it seems like they think of SSRIs for anxiety as a one-size-fits-all solution.
>
>
> Kaiser treats all mental illness like a one-size-fits-all... their solution to everything is group sessions and whatever drug is hot on the market. We're all just on their assembly line, bring 'em in, ask a couple questions, and send them away with a medication. Don't bother them furthur. Just take your drugs. If the drug isn't working, it must be something you're doing wrong. Seriously. This is what I got when I was there. Never again. Got rid of them in January, and since have gotten competent help and have improved a lot.
> >
> > Which strikes me as a too-general a rule if it's true. i.e. that they'd rather have patients face the real side effects of a SSRI than deal with the possibility of a patient getting tolerant or addicted to Klonopin in the future.
> >
>
> But see, they still lie about the side effects. Ok, maybe they've stopped lying about the common side effects, but they still lie about the withdrawal. I wish doctors would quit getting so bent out of shape over benzos. I haven't really seen a better class of drugs for anxiety. They keep trying by putting it on another label, but I'm not convinced.
>
> -Bonnie
>
>I'm so sorry you have had bad experiences with Kaiser Permanente. However, I feel it is important for me to share my experiences with my Kaiser Permanente HMO here in Atlanta.
My pdoc is amazing. He listens to me, and always tells me how important it is that I am trying to help myself by researching medications. Whenever I have suggested any medication, he has been willing to try it and prescribed it for me.
Both of the therapists I have seen were great, and the nurse practitioner who I was first assigned to was also very good. She realized that I was a "tough case" early on and knew that I should be seeing the pdoc directly, and took care of it.
I would recommend trying a different Kaiser Permanente location, if there is one near you, or switching to another pdoc at the clinic you are going to now. I think that I was told that each behavioral health clinic has to have at least 2 pdocs and 2 nurse practitioners, although I know that at mine one of the pdocs is strictly a pediatric pdoc, unless the other two are away at the same time and he has to fill in.
Best of luck to you!
Posted by med_empowered on August 3, 2007, at 8:25:10
In reply to Re: I wonder about Kaiser. (pdoc + SSRIs for anxie » Bonnie_CA, posted by BGB on August 3, 2007, at 7:01:09
are you sure its Kaiser that's setting up restrictions on Klonopin? I mean, look at it like this: benzos are dirt cheap, and only *some* patients take them for very long. Lots of patients on SSRIs end up needing them, anyway. Plus despite benzo-phobia, benzos are still really, really popular...I think maybe its your doc.
I think its ridiculous how docs assume that SRIs/SNRIs, etc. are going to make someone feel better. They're not that great, really. And they don't work on GABA. I mean, if you respond to benzos, why should you respond to an AD? Its an apples-to-oranges comparison; the drugs work by entirely different means (and in controlled trials, the benzos are way better for anxiety than the ADs, which often fail to beat placebo).
If you have the $$$, maybe you should pay somebody out-of-pocket for 1 or 2 sessions, then skip back over to Kaiser with your Klonopin rx in hand. Rational docs have no probs with the benzos; I even had a doc tell me that I wasn't "a good candidate for ssri therapy" and start me off on Klonopin. You might also be able to find another Kaiser doc who hasn't been brainwashed by the DEA.Anyway: sorry about your situation. Good luck to you.
Posted by yznhymer on August 5, 2007, at 19:43:19
In reply to klonopin..., posted by med_empowered on August 3, 2007, at 8:25:10
I'm still at the same .5mg klonopin prescription I was started on about 15 years ago. I use it sporadically, or "as needed". Its also useful to help me stay asleep. I never had any abuse problem with it nor did I develop a tolerance, even though, if forced to be honest, I'd probably say I have an addictive personality. A 30 day prescription typically lasts me 6 weeks, sometimes more. My previous pdoc was comfortable supplying 90-day prescriptions with refills at a time so I could mail order it through my insurance.
My reaction to AD's, particularly SSRI's, mirrors yours and those of others - I find them very agitating and anxiety producing to the point of having to discontinue them. I was worse off taking them than taking nothing at all. Seriously. All the negative side effects and none of the benefits. (Seem to be doing well with EMSAM so far tho).
I'd say you know your experience best and sound like you're clear about the issues. I wouldn't hesitate to do whatever you need to do to get the treatment you decide is best for you. Its a shame you have to go up against what appears to be a small medical mind.
As an aside, I had mixed experiences with Kaiser in the northern Virginia area. Their pediatrics dept. was excellent. Adult medicine was cold and factory-like. I ultimately opted for a more expensive BCBS plan just because the Kaiser mental health benefits were totally inadequate at that time. They did not provide individual therapy and all their groups were "full". I suspect that has changed. Ironically, I randomly saw a new psychiatrist for my very last (emergency) visit who was great. I was hallucinating and developed weird blotches on my legs from an anti-psychotic prescribed for anxious depression. What a trip that was. Anyway, I would have stuck it out with Kaiser if I'd met that last pdoc before that point.
There's nothing quite like wrestling around with "the system" when you're gripped by anxiety, feel outgunned, and they hold most of the cards. Still, you can maneuver your way around this to get what you need. It is part art, part science. If you can afford it, you might want to bypass Kaiser on this one if nothing else works. It would be money well spent. Good luck to you.
Y
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