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Dr. Bob is Robert Hsiung, MD,
bob@dr-bob.orgShown: posts 1 to 19 of 19. This is the beginning of the thread.
Posted by jono_in_adelaide on January 29, 2013, at 20:46:21
I'll start by saying that I am very lucky, that my depression is very well controlled by the cocktail of reboxetine, sertaline and risperidone.
However, I am still often bothered by disabeling anxiety, even when taking Xanax 1mg three times a day
Thinking about my options, i have come up with the following
- Drop sertaline and risperidone and substitute mirtazapine 30-45mg at night. I have never felt that SSRI's do much for me, and I'm wondering if mirtazapine might be better against anxiety than low dose risperidone (1.5mg at bedtime)
- Drop sertaline and reboxetine and start nardil with or without nortriptyline. I'm sure Nardil would help the anxiety, but the side effects worry me, I get no side effects from my current drugs apart from a bit of dry mouth and delayed orgasm (sory if that was TMI)
- Change the 1mg alprazolam tid to 1mg clonazepam tid (clonazepam is both more potent and longer action, so I'd effectively be giving my self a dose increase of benzo) I worry that this might be the slippery slope to ending up like Elvis.
Any thoughts or comments or advice anybody could offer?
Posted by SLS on January 29, 2013, at 21:56:56
In reply to My Anxiety - the end of the road, posted by jono_in_adelaide on January 29, 2013, at 20:46:21
> I'll start by saying that I am very lucky, that my depression is very well controlled by the cocktail of reboxetine, sertaline and risperidone.
>
> However, I am still often bothered by disabeling anxiety, even when taking Xanax 1mg three times a day
>
> Thinking about my options, i have come up with the following
>
> - Drop sertaline and risperidone and substitute mirtazapine 30-45mg at night. I have never felt that SSRI's do much for me, and I'm wondering if mirtazapine might be better against anxiety than low dose risperidone (1.5mg at bedtime)
>
> - Drop sertaline and reboxetine and start nardil with or without nortriptyline. I'm sure Nardil would help the anxiety, but the side effects worry me, I get no side effects from my current drugs apart from a bit of dry mouth and delayed orgasm (sory if that was TMI)
>
> - Change the 1mg alprazolam tid to 1mg clonazepam tid (clonazepam is both more potent and longer action, so I'd effectively be giving my self a dose increase of benzo) I worry that this might be the slippery slope to ending up like Elvis.
>
> Any thoughts or comments or advice anybody could offer?
Perhaps substituting nortriptyline for reboxetine makes sense at this juncture. I question the degree to which reboxetine can address anxiety. I am concerned that it might actually be contributing to it. I am guessing that you are using the risperidone for 5-HT2a antagonism, but nortriptyline might be a better fit. If you need the 5-HT7 antagonism, you could continue with risperidone or switch to Latuda. I find nortriptyline to be more pleasant and calming than the more potent and selective NRI, desipramine. You know that I am not a big fan of reboxetine, mostly because the statistical and anecdotal data are not that impressive. However, in addition, my personal experience with reboxetine was disastrous. It precipitated a severe anxious and suicidal depressive state. I was ready to die. Desipramine does not affect me that way.Is there any reason why you can't add the mirtazapine first, and then attempt to discontinue the other drugs sequentially? Mirtazapine might work in concert with sertraline in a way similar to the "rocket fuel" combination using Effexor. For what it is worth, I did better with Effexor + nortriptyline than with sertraline + nortriptyline.
Regarding Nardil, it might make a good monotherapeutic substitute for your present treatment. I do better when I use nortriptyline in combination with Nardil, but I find that hypotension and urinary retention become more problematic. It is too bad that Zyprexa produces so much weight gain and diabetes. It might otherwise work well with Nardil for anxious or bipolar depressions. As it is, you might expect a certain amount of weight gain with Nardil alone. For refractory GAD or SA, adding clonazepam to Nardil would be an interesting choice.
You might want to try substituting nortriptyline for reboxetine, perhaps using a cross taper/titration first, and determine which of the two works better for you. You could then add mirtazepine if necessary. I would leave Nardil for last, only because it would preclude your use of sertraline and perhaps even mirtazapine. I am not aware of the use of an MAOI in combination with mirtazapine. I would think that serotonin syndrome would be less of a concern than a hyperadrenergic reaction. I am not sure.
You'll figure it out.
- Scott
Posted by Phillipa on January 29, 2013, at 22:26:18
In reply to Re: My Anxiety - the end of the road » jono_in_adelaide, posted by SLS on January 29, 2013, at 21:56:56
I'd substitute the klonopin for xanax as more potent but is unlikely to cause you to need to take more. Remeron did nothing for me even at 15mg. Phillipa
Posted by jono_in_adelaide on January 29, 2013, at 23:07:35
In reply to Re: My Anxiety - the end of the road » jono_in_adelaide, posted by SLS on January 29, 2013, at 21:56:56
I've done the reboxetine/nortriptyline (and bupropion) comparison in the past Scott, and found that there wasnt much to choose between them for me. Nortriptyline had a mild anxiolytic effect as monotherapy, but the difference disapeared when risperidone 1mg was added.
I'll give all your suggestions some thought - I might have to try several and see which one works for the best.
Oh, for there to be just one pill I could take once a day, that would make everything allright
Posted by jono_in_adelaide on January 29, 2013, at 23:19:51
In reply to Re: My Anxiety - the end of the road, posted by jono_in_adelaide on January 29, 2013, at 23:07:35
If it allowed me to be normal without harming my personality or interllect, I'd even try
Posted by gadchik on January 30, 2013, at 9:34:15
In reply to Re: My Anxiety - the end of the road, posted by jono_in_adelaide on January 29, 2013, at 23:19:51
i found that klonopin is the only pill i need for anxiety and depression. good luck to you.
Posted by ChicagoKat on January 30, 2013, at 10:01:33
In reply to My Anxiety - the end of the road, posted by jono_in_adelaide on January 29, 2013, at 20:46:21
> I'll start by saying that I am very lucky, that my depression is very well controlled by the cocktail of reboxetine, sertaline and risperidone.
>
> However, I am still often bothered by disabeling anxiety, even when taking Xanax 1mg three times a day
>
> Thinking about my options, i have come up with the following
>
> - Drop sertaline and risperidone and substitute mirtazapine 30-45mg at night. I have never felt that SSRI's do much for me, and I'm wondering if mirtazapine might be better against anxiety than low dose risperidone (1.5mg at bedtime)
>
> - Drop sertaline and reboxetine and start nardil with or without nortriptyline. I'm sure Nardil would help the anxiety, but the side effects worry me, I get no side effects from my current drugs apart from a bit of dry mouth and delayed orgasm (sory if that was TMI)
>
> - Change the 1mg alprazolam tid to 1mg clonazepam tid (clonazepam is both more potent and longer action, so I'd effectively be giving my self a dose increase of benzo) I worry that this might be the slippery slope to ending up like Elvis.
>
> Any thoughts or comments or advice anybody could offer?I like options 1 or 2. I agree with you about the worry of benzos being a slippery slope, and I feel they really shouldn't be used for chronic anxiety.
I like the idea of trying mirtazapine first. You wouldn't have to do a washout, and there's no doubt it would help your anxiety. I get anxiety a lot, and mirtazapine was pure bliss to me. It's also great that it is a very effective antidepressant too.
Then,, if you couldn't tolerate the side effects of mirtazapine, or it just didn't work well for you, you could go ahead with a try of Nardil. Nardil's a pain, there's no doubt, what with the washouts and all the food and drug interactions. But it is an excellent anxiolytic and an excellent antidepressant. And tbh, the food interactions were not in the least difficults to deal with. It's just important you educate yourself about other meds that could interact with it - especially when a lot of docs (aside from pdocs) have no clue.
Good luck with your decision!
Kat
p.s. I personally find anxiety more difficult to deal with than depression, so don't feel at all as if you don't have a big deal problem. Chronic anxiety is definitely a big deal!
Posted by SLS on January 30, 2013, at 10:26:39
In reply to Re: My Anxiety - the end of the road, posted by jono_in_adelaide on January 29, 2013, at 23:19:51
I forgot to mention that risperidone can produce anxiety in some while reducing it in others.
- Scott
Posted by B2chica on January 30, 2013, at 12:15:15
In reply to My Anxiety - the end of the road, posted by jono_in_adelaide on January 29, 2013, at 20:46:21
when my anxiety kicks up severly my pdoc put me on low dose perphenazine. it worked very well combined with my gabapentin.
Posted by jrbecker76 on January 30, 2013, at 15:40:14
In reply to Re: My Anxiety - the end of the road » jono_in_adelaide, posted by SLS on January 29, 2013, at 21:56:56
At first, I thought my anxiety got better with using NRIs (reboxetine and milnacipran) but I noticed after taking them chronically that they drastically increased my ruminative thoughts.
Posted by jono_in_adelaide on January 30, 2013, at 16:47:07
In reply to Re: My Anxiety - the end of the road, posted by jrbecker76 on January 30, 2013, at 15:40:14
Thanks for the pointer Scott, I'm def one of those whos anxiety (and depression) (and interestingly, so did low dose melleril when I tried in once many years ago)
I took my first 1mg pill at night, and the next morning, I felt better, not totaly better, but i could feel the improvement.
I'm especialy interested in Nardil because of its action on GABA - it could be the answer for me, but I am loathe to mess with the antidepressant cocktail I'm on because it has me in complete remission, after a long time messibng around with things that didnt work.
I think I'll put it on ice till the weekend and try and think it through then.
If it wasnt for the drugs, I wouldnt be able to be working in the position i am now, I have made such huge gains in the last 2 years (going from not having worked in a year, to warehouse lackey, to warehouse supervisor, to logisitcs manager) and I am terrified of mlting down and losing them all.
So, I'm determined to hold it together, even if itvolves IV Thorazine!
Posted by jono_in_adelaide on January 30, 2013, at 17:16:14
In reply to Re: My Anxiety - the end of the road, posted by jrbecker76 on January 30, 2013, at 15:40:14
And thanks everybody for your concern and suggestions!
Posted by jono_in_adelaide on January 31, 2013, at 16:44:36
In reply to Re: My Anxiety - the end of the road, posted by jono_in_adelaide on January 30, 2013, at 17:16:14
Not sure wether to drop Zoloft and start mirtazepine, or drop reboxetine and add nortriptyline. I think the nortriptyline option would cause less sedation and weight gain, but I suspect the mirtazapine option might be more effective for anxiety.
I'll think about it over the weekend, and probably end up tossing a coin!
Posted by jono_in_adelaide on January 31, 2013, at 18:54:55
In reply to Re: My Anxiety - the end of the road - SLS, posted by jono_in_adelaide on January 31, 2013, at 16:44:36
I've decided to try the nortriptyline route first - drop the reboxetine and add nortriptyline.
Hopefully the 5HT2A antagonist effect will help the anxiety and the NARI activity will maintain the antidepressant effect.
If this avenue doesnt work, then i guess I'll try dropping sertaline and adding mirtazapine, and see where that leads
If that turns out to be a dead end, there is always nardil, wht GABA activity of which interests me greatly
Posted by SLS on February 1, 2013, at 2:23:03
In reply to Re: My Anxiety - the end of the road - SLS, posted by jono_in_adelaide on January 31, 2013, at 18:54:55
> I've decided to try the nortriptyline route first - drop the reboxetine and add nortriptyline.
>
> Hopefully the 5HT2A antagonist effect will help the anxiety and the NARI activity will maintain the antidepressant effect.
>
> If this avenue doesnt work, then i guess I'll try dropping sertaline and adding mirtazapine, and see where that leads
>
> If that turns out to be a dead end, there is always nardil, wht GABA activity of which interests me greatly
Good luck!There will be a whole lot of us rooting for you.
I like the idea of Nardil. You might even be able to tolerate it in combination with nortriptyline.
It is too bad that vigabatrin (Sabril) can cause irreversible damage to vision. It is a potent GABA transaminase inhibitor. I have heard that lemon balm can inhibit this enzyme, as well as valproate. Tiagabine (Gabitril) is a GABA reuptake inhibitor. It is unpredictable, though. It is anxiolytic in some people and agitating in others
There is some evidence that gabapentin increases the rate of rate of synthesis of GABA via glutamic acid decarboxylase. Some people experience a sustained anxiolytic effect at low dosages (600 - 900 mg/day). I react badly to it, though. Both gabapentin and pregabalin affect me the same way. They make my depression worse and produce cognitive impairments that can last for weeks after discontinuation. I attribute this to its interaction with the alpha2delta subunit of the calcium channel. Of course, not everyone experiences this.
Like I said, you'll figure it out.
- Scott
Posted by jono_in_adelaide on February 3, 2013, at 19:27:25
In reply to Re: My Anxiety - the end of the road - SLS » jono_in_adelaide, posted by SLS on February 1, 2013, at 2:23:03
After thinking about it over the weekend, I'm begining to wonder wether i should try nortriptyline or mirtazapine first
Nortriptyline will have a better side effect profile, but mirtazapine might have the edge on effectiveness.
I think I'm also going to ask about changing from alprazolam to clonazepam
I just dont want tomess with what has taken my depression from suicidal to total remission and screw that up in the process, but I need to do somthing, the anxiety and avoidant beheivior is effecting my work performance, and I am determined not to screw this up - i am determined I am going to keep working in some sort of a managament roll, even if I have to be doped on whatever to do it
Posted by Phillipa on February 3, 2013, at 21:29:46
In reply to Re: My Anxiety - the end of the road - SLS, posted by jono_in_adelaide on February 3, 2013, at 19:27:25
Jono ever taken klonopin before as the time I tried to switch from xanax to klonopin felt suicidal and wasn't so the doc said the med. Phillipa
Posted by SLS on February 3, 2013, at 22:15:01
In reply to Re: My Anxiety - the end of the road - SLS, posted by jono_in_adelaide on February 3, 2013, at 19:27:25
> After thinking about it over the weekend, I'm begining to wonder wether i should try nortriptyline or mirtazapine first
>
> Nortriptyline will have a better side effect profile, but mirtazapine might have the edge on effectiveness.
>
> I think I'm also going to ask about changing from alprazolam to clonazepam
>
> I just dont want tomess with what has taken my depression from suicidal to total remission and screw that up in the process, but I need to do somthing, the anxiety and avoidant beheivior is effecting my work performance, and I am determined not to screw this up - i am determined I am going to keep working in some sort of a managament roll, even if I have to be doped on whatever to do itTough decision.
Don't forgo an opportunity to combine nortriptyline with mirtazapine. I believe Linkadge is having success combining amitriptyline with mirtazapine. I haven't seen anyone else use this strategy, but it is interesting.
I don't like reboxetine. My personal bias leads me to suggest switching from reboxetine to nortriptyline or desipramine. Hopefully, you will retain the antidepressant response and not need mirtazapine. Of course, it is possible that reboxetine is your best friend. I would not presume to know how your system would react to a change in treatment.
- Scott
Posted by jono_in_adelaide on February 4, 2013, at 0:43:41
In reply to Re: My Anxiety - the end of the road - SLS » jono_in_adelaide, posted by SLS on February 3, 2013, at 22:15:01
I know reboxetine got a very bad review in the BMJ a couple of years ago, butr for me it was a wonder drug - after failing multiple antidepressants, I was given reboxetine and sertaline and within a week felt better.
I have since tried substituting the reboxetine with nortriptyline and bupropion, and have found little to choose between them (desipramine is no longer on the market in Australia)
As well as helping the depression, the reboxetine seemed to help reduce the panic attacks as well, havingsaid that, I'm going to give nortriptyline another try and see if things have changed.
This is the end of the thread.
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