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Dr. Bob is Robert Hsiung, MD,
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Posted by dannen on October 23, 2003, at 13:23:10
In reply to Re: Agitated depression; anxiety bad in morning » dannen, posted by zeugma on October 23, 2003, at 5:11:51
Zeugma. Thanks. Do you have to have your blood checked to determine if 75 mg. is at the theurapeutic level? My psychiatrist seems unfamiliar with TCAs, and that might be an obstacle to him prescribing a TCA. I have read the TCAs are better for melancholic depression, especially in men over 40 (nortriptyline). I hope I can get it and then tolerate it. I also am thinking about gabitril for sleep or doxepin for sleep. But I think I probably need more than help with my sleep. Have you ever tried St. John's Wort (SJW)? I only bring it up because I have such a hard time tolerating any medicine, and SJW apparently is relatively easy to tolerate.
THANKS AGAIN FOR YOUR KINDNESS. Dannen
Posted by Viridis on October 23, 2003, at 14:05:12
In reply to Re: Agitated depression; anxiety bad in morning, posted by dannen on October 23, 2003, at 13:17:26
Hi Dannen,
Xanax seems to be one of the worst benzos for building tolerance -- I've had that experience too, so now just use it occasionally. Klonopin (clonazepam) seems to be quite different; I've been on the same dose for a long time, and my pdoc has lots of other patients who have been on the same dose for many years. He's very cautious with Xanax, and based on his experience much prefers to prescribe Klonopin. It's very subtle, but really works for anxiety. It also has mood-stabilizing effects for some people (like me). Of course, you are likely to become dependent on it, as you would with most antidepressants, so need to discontinue it gradually if you decide to stop using it.
Strattera isn't stimulating for me, but I do take it (and Adderall, an amphetamine) primarily for ADD, so I could be a special case. With Strattera, I'd definitely recommend starting with a low dose (say, 25 mg) and working up gradually. So often, the doctors want you to try a full dose of these meds right from the start, and the side effects from many can be intolerable that way. I always like to start low and go slow. Having an anti-anxiety med like Klonopin in place first can help the transition greatly.
I haven't tried tricyclics, but know several people who have really benefitted from them. I'm not aware of any evidence that the newer ADs are any better (on average) than the older tricyclics that are now off-patent (and so not heavily marketed).
Good luck!
Posted by zeugma on October 23, 2003, at 18:44:48
In reply to Re: Agitated depression; anxiety bad in morning, posted by dannen on October 23, 2003, at 13:23:10
Hi Dannen,
As Viridis says it seems that tolerance develops less with Klonopin than with Xanax. Right now I feel I could use some Klonopin... i am prone to anxiety-induced freakouts that result from extreme inhibition and self-consciousness. I may have to tell my pdoc (see him tommorow)my latest story...I also take Strattera and it is a good med, it treats my inattentive ADD symptoms and is a fairly tolerable drug. Similar to nortriptyline in terms of side effects (dry mouth and constipation, dry skin, dry hair etc.).
About nortriptyline dosage: I was on 60 mg when my pdoc ordered blood levels. I was still experiencing ADD symptoms (TCA's also help ADD a little). I was just under the window, maybe 45ng/mL. I raised it to 75 mg which puts me just inside the 58-148 ng/mL window. Nothing comparable exists for any of the newer AD's. The advantage is that it reliably correlates with response, so you can adjust the dosage rationally rather than by guesswork, and the window is well documented, so your pdoc can just consult a standard reference work to determine where your blood levels fall.
Posted by dannen on October 23, 2003, at 18:51:39
In reply to Re: Agitated depression; anxiety bad in morning » dannen, posted by zeugma on October 23, 2003, at 18:44:48
Zeugma. THANKS.
I will be meeting with my pdoc in about an hour, and I will suggest nortriptyline. I hope I can tolerate it. I have been unable to tolerate anything so far (the SSRIs [agitation], Remeron [fast pulse], Wellbutrin [great agitation], Lamictal [agitation]). But I have never tried a TCA. I hope TCAs are different.I really appreciate the information and your kindness. God bless you.
Dannen
Posted by zeugma on October 23, 2003, at 20:19:52
In reply to Re: Agitated depression; anxiety bad in morning, posted by dannen on October 23, 2003, at 18:51:39
> Zeugma. THANKS.
> I will be meeting with my pdoc in about an hour, and I will suggest nortriptyline. I hope I can tolerate it. I have been unable to tolerate anything so far (the SSRIs [agitation], Remeron [fast pulse], Wellbutrin [great agitation], Lamictal [agitation]). But I have never tried a TCA. I hope TCAs are different.
>
> I really appreciate the information and your kindness. God bless you.
Dannen,You're very welcome. Let us know what your pdoc says. I hope he is able to help you.
z
>
> Dannen
Posted by dannen on October 24, 2003, at 14:20:36
In reply to Re: Agitated depression; anxiety bad in morning » dannen, posted by zeugma on October 23, 2003, at 20:19:52
Viridis and Zeugma. Pdoc prescribed nortriptyline. It comes in a liquid form, which he had the pharmacy order. I am very sensitive to meds, so he wants me to titrate up slowly. He has several other patients who use it. He is older, so he prescribed TCAs before the SSRI era began in the late 1980s. That gave me some comfort. I asked about the therapeutic window (which I have seen variously as 30ng-150ml and 50ng-150ml), but he said that such range is not hard and fast, and that he has seen people respond on much lower doses. (He said has has some patients on Prozac at 1 and 2 mg.) He said that no blood tests would be required. Anyway, I'm going to start next week when the med comes in, and then see if I can tolerate it. He wants me to start at 1 mg and work up. That may sound silly, but I am SO sensitive to meds. When I used to drink alchohol, one beer used to make me drunk. One cup of coffee would make me high. So, he thinks that even 10 mg may be sufficient. That contradicts what I have read about Pamelor/Aventil online, and what you two suggest. I hope it works. Comments appreciated. Thanks. Dannen
Posted by Viridis on October 25, 2003, at 2:33:05
In reply to Re: Agitated depression; anxiety bad in morning, posted by dannen on October 24, 2003, at 14:20:36
Hi Dannen,
It sounds like you have a very reasonable doctor who appreciates your medication sensitivity. Again, I have no experience with tricyclics (beyond what friends have told me), but my understanding is that they can be very effective. I will emphasize though that, if you have anxiety issues or weird stress reactions while you're adjusting to the new meds, benzos can be very helpful and you shouldn't be afraid to ask for them. I'd recommend clonazepam, although obviously your doctor knows you best.
Good luck!
Posted by dannen on October 26, 2003, at 19:04:55
In reply to Re: Agitated depression; anxiety bad in morning » dannen, posted by Viridis on October 25, 2003, at 2:33:05
Viridis. Thanks again for the advice. I took a benzo for a month in August 2002--Xanax. It is horrible stuff. They won't even prescribe it at one hospital I visited last summer because of additive potential. Check the web. It can be dangerous. Klonopin apparenly is much milder. My sister-in-law is a pharmacist, and she has taken it for some time for sleep. I wouldn't know. Right now, I need to find a TCA I can tolerate that can reduce my agitated depression. I am told that nortriptyline may be the right choice. Wish me luck. Best to you. Dannen
Posted by Viridis on October 28, 2003, at 2:01:53
In reply to Re: Agitated depression; anxiety bad in morning, posted by dannen on October 26, 2003, at 19:04:55
I've found Xanax very helpful, but I did build tolerance to it quite suddenly and now have to take much more to achieve the same effect than I did initially. Since I've always used it just as an occasional adjunct to Klonopin, this really hasn't caused me any problems. However, its short half-life, combined with the potential for tolerance and thus the need for higher doses, can cause problems for some people, especially those who use it regularly. My pdoc is quite willing to prescribe a set (fairly small) amount every three months, but also says that if my frequency of use increases, that's a cause for concern. Fortunately, I haven't had any desire to use it more often (once every week or two, on average). He doesn't seem nearly as comfortable with it as with Klonopin.
Klonopin is powerful stuff too, but I find it much more subtle, and most people seem to be able to get anxiety relief with the same dose for long periods of time. That's been my experience, and my pdoc says the same thing is true for many of his patients. However, like all benzos (and most antidepressants), if you decide to quit it, you need to do so gradually. Klonopin's gentle effects and long half-life may make it seem milder than Xanax, but it's a very potent med. However, so are most of these psychiatric drugs. They all change your brain chemistry, after all (which is what they're supposed to do, for the better) and if you've been using any of these meds for long it's best to discontinue slowly.
Posted by dannen on October 28, 2003, at 12:37:49
In reply to Re: Agitated depression; anxiety bad in morning » dannen, posted by Viridis on October 28, 2003, at 2:01:53
Viridis or Zeugma. Have either of you experience with having blood plasma levels checked after taking nortriptyline? At what point is this done? I read that one should have this done after being at 75 mg for 7 days. Any guidance.
Viridis. Thanks for the information on Xanax and Klonopin. Can one take Klonopin every day, without the risk of needing more (i.e., developing a tolerance)? My sister-in-law takes it 5 days on, 2 days off I think. I knew a priest who got up to 20 mg a day. (Yes, that amount seems impossible, but it is true. He was detoxed at a hospital over several months. A very kindhearted man who get horrible advice from his doctor.)
I need an antidepressant that works for anxiety. My morning anxiety is brutal. The SSRIs did not work, nor any of the newer ADs. So, I am trying nortriptyline as one of the cleaner TCAs and one not as activating as desipramine. Or so I'm told. I start this Thursday, with a very low dose (liquid form).
Thanks. Dannen
Posted by zeugma on October 28, 2003, at 20:33:35
In reply to Re: Agitated depression; anxiety bad in morning, posted by dannen on October 28, 2003, at 12:37:49
> Viridis or Zeugma. Have either of you experience with having blood plasma levels checked after taking nortriptyline? At what point is this done? I read that one should have this done after being at 75 mg for 7 days. Any guidance.
Dannen,
I had my plasma level taken after a month at 60 mg/ day. The trick with nortriptyline is that people metabolize it at very different rates, hence 60 mg a day could be a high dose for one person (while that's fairly unlikely) but low for many others. The plasma level was 'low,' according to my pdoc, so we raised it to 75 mg a day. The response became stronger at that point.
You'll want to titrate up slowly, because nortriptyline tends to have a lot of side effects, that will mostly go away over time. On the other hand, it is much easier on the stomach than a lot of other AD's, and seems to have some kind of anti-nauseant property, in addition to being a good analgesic (its other main use is in conditions of chronic pain, and further up this board there's discussion of its efficacy in migraines).
I still suffer from anxiety- at this point, I am considering a benzodiazepine such as Klonopin prn, for situations that are especially anxiety-provoking. I have a particularly debilitating form of social anxiety, and TCA's generally don't help this condition. They do lower the anxiety level overall. The sedative effect is subtle at low doses- when I was taking 40 mg, I had to take it at 2 pm to get to sleep by midnight (I am a lifetime insomniac). I can take 75 mg at 8 pm to be in bed by 11. It's also made my sleep more restful. A lot of my morning anxiety came from having such bad sleep that I did not feel like a human being when I woke up.
zeugma
>
> Viridis. Thanks for the information on Xanax and Klonopin. Can one take Klonopin every day, without the risk of needing more (i.e., developing a tolerance)? My sister-in-law takes it 5 days on, 2 days off I think. I knew a priest who got up to 20 mg a day. (Yes, that amount seems impossible, but it is true. He was detoxed at a hospital over several months. A very kindhearted man who get horrible advice from his doctor.)
>
> I need an antidepressant that works for anxiety. My morning anxiety is brutal. The SSRIs did not work, nor any of the newer ADs. So, I am trying nortriptyline as one of the cleaner TCAs and one not as activating as desipramine. Or so I'm told. I start this Thursday, with a very low dose (liquid form).
>
> Thanks. Dannen
Posted by dannen on October 28, 2003, at 20:48:33
In reply to Re: Agitated depression; anxiety bad in morning » dannen, posted by zeugma on October 28, 2003, at 20:33:35
Zeugma.
Thanks so much for your help. I am sorry about your social anxiety. Have you ever tried yoga? It is the only thing that really has helped my anxiety. Acupuncture also is very good, if the person knows his/her stuff. But it is tricky treating a mixed state like anxious depression. Yoga and swimming are my main crutches right now.
I do not have trouble falling asleep. It's staying asleep. I fall asleep about 10:30 and awake at about 4:30. And the anxiety starts. Free floating. No bad thoughts or dreams. Just waves of anxiety. I hope nortriptyline can help with that. I will have my blood level checked when I get higher up in the mgs, I guess. I am just starting with 5-10 mgs. this week. I'll work up.
What helps for the side effects--dry mouth and constipation? Is there any counteracting med for that? I might make a post on that.
Again, thanks for caring. I wish you the best in finding that peace that passes all understanding.
Dannen
Posted by zeugma on October 28, 2003, at 22:26:46
In reply to Re: Agitated depression; anxiety bad in morning, posted by dannen on October 28, 2003, at 20:48:33
Dannen,
That early wakening is a classic sign, it's called 'terminal insomnia.' It was identified early on in the history of psychopharmacology as a marker of a potential POSITIVE response to TCA's.
The first things nortriptyline did, ata very low dose (20-30 mg a day)were:
cut down on my constant nausea;
stop the kind of anxiety you may be describing, a disruptive feeling I would call an 'inner shivering.'
I hope nortriptyline helps you sleep through the night. I believe that many of its therapeutic actions are mediated through its regulation of the sleep cycle. My sleep problems have always centered around a chaotic sleep schedule, no matter how hard I tried I could not fall asleep at the same time every night. Then when I would sleep it would be the wrong kind of sleep. This os a different problem from yours, but I hope nortriptyline can help you stay asleep until you want to wake up.
The side effects I got early on were lowered blood pressure, headache (from dehydration), aqnd dizziness. The solution was to drink plenty of liquids, which also helps with the constipation and dry mouth, though I didn't get those until I reached a higher dosage. Also, a certain degree of increased emotionality can occur. I believe this drug is a powerful 'normalizer' of emotions, and this can cause some agitation; it's something to watch out for, but I think it is part of the therapeutic action.Thanks for the positive wishes, and wishing you the best in return,
zeugma
Posted by Viridis on October 29, 2003, at 2:35:24
In reply to Re: Agitated depression; anxiety bad in morning, posted by dannen on October 28, 2003, at 12:37:49
Hi Dannen,
I don't have any experience with TCAs, so can't help there. Re: Klonopin: I've been taking 1 mg Klonopin per day for 2 1/2 years and haven't changed the dosage except for very rarely taking an extra mg later in the day (only for really intense stress, maybe once a month).
There are no guarantees, but my pdoc says he has many patients who have been on the same dose for years and are doing well. He's offered to increase my dose (1 mg is at the very low end for serious anxiety/panic) but I've had no need so far and don't want to increase it unless I absolutely have to. Generally, I use Xanax for "breakthrough" anxiety, but given my sudden tolerance to Xanax I keep its use to a minimum. It is very helpful as a backup, though, and normally Klonopin is enough anyway.
BTW, Klonopin was originally used for epilepsy, and up to 20 mg/day was/is a pretty common dose for that condition. I can't imagine taking that much! No matter how much you take, though, if you take it for long, you need to diminish the dose gradually should you decide to quit it. This seems to be the case for almost all of these psychiatric meds (and lots of others too, like some blood pressure drugs etc.).
If I were you, I'd give Klonopin a trial for a couple of weeks -- I suspect it will help a lot, especially together with nortriptyline. The morning anxiety syndrome is awful, and I've had plenty of experience with it. I never want to go back there, and will stick with the meds for life if necessary.
Posted by dannen on October 29, 2003, at 13:54:18
In reply to Re: Agitated depression; anxiety bad in morning » dannen, posted by zeugma on October 28, 2003, at 22:26:46
Zeugma. Thanks so much for the advice and information. It is very reassuring. I will increase the fluids. I discovered a product called Mouth Kote that helps with dry mouth. Putting a lemon in water also helps. I get the nortriptyline tomorrow. I will keep you informed. Again, I really appreciate you kindness. We're all carrying a burden. You've lightened mine. Dannen
Posted by dannen on October 29, 2003, at 15:59:40
In reply to Re: Agitated depression; anxiety bad in morning » dannen, posted by Viridis on October 29, 2003, at 2:35:24
Viridis. Thanks for the information on Klonopin. There is so much anti-benzo information out there, I have been scared off. My experience with Xanax was horrible. Worst anxiety one can imagine when I stopped. Klonopin may be safer. It may be worth a try, at a low dose. Do you take it at night or throughout the day? I only need help in the am. I am all right after about noon. Thanks so much. Dannen
Posted by Viridis on October 30, 2003, at 0:33:21
In reply to Re: Agitated depression; anxiety bad in morning, posted by dannen on October 29, 2003, at 15:59:40
Hi Dannen,
I started off taking Klonopin at night, in part because it can make you sleepy at first and in part because it has a very long half-life so (theoretically) should last through the next day. I found that the effects wore off by about noon the next day, so for a short while I took divided doses 4X, then 2X a day to minimize side effects. After a couple of weeks, the side effects (which were mild to begin with) disappeared and I just started taking the whole 1 mg in the morning.
It sounds like the night-dosing strategy could work well for you, and this is what a lot of doctors seem to prefer anyway. Plus, if you do have side effects like drowsiness or foggy thinking at first, you should just sleep through the worst of it.
Just curious, but did you stop the Xanax suddenly or taper off gradually? "Rebound" anxiety can be bad with these meds if you take them for a while and then just stop -- it's important to slowly cut back the dose. Xanax seems to be especially bad because it has a fairly short half-life and leaves your system quickly, whereas Klonopin does so much more gradually. But with any of these, tapering down is essential if you go off them.
Posted by dannen on October 30, 2003, at 12:24:41
In reply to Re: Agitated depression; anxiety bad in morning » dannen, posted by Viridis on October 30, 2003, at 0:33:21
Viridis. I tapered off the Xanax, but probably not slowly enough. If you do a search on the Web, you will find very negative reports on Xanax from hospitals and detox facilities. As I wrote in an earlier post, some doctors simply will not prescribe Xanax because they consider it dangerous. It is used a party drug because of its euphoric effect. Not so with Klonopin. I would consider Klonopin but never Xanax again. Thanks for the advice. Best of luck with the Klonopin. Dannen
Posted by Clayton on October 31, 2003, at 13:22:16
In reply to Agitated depression; anxiety bad in morning, posted by dannen on October 21, 2003, at 21:32:22
I awakened with both severe (intolerable) mood and aggitatted depression.
Prozac didn't help.
Paxil didn't help very much.
A new pdoc aded Remaron to the Paxil (they are synergistic). I had become very pesimestic about meds. Surprise! This combo worked. I mean that within a week, it was 90% efficacious! Without exaggeration, it saved my life and freed me from pain and isolation. I am now a happy morning person for the first time in my life.
It also helped some other axxiety disorders. SAD and insomnia. SAD 95% controlled. Insomnia down about 80%.
What have you got to loose?
Posted by dannen on October 31, 2003, at 13:34:30
In reply to Re: Morning Depression - What worked well for me » dannen, posted by Clayton on October 31, 2003, at 13:22:16
Clayton. Thanks for the input. I took Remeron for about two months in 2002. It caused me to be really agitated--high blood pressure and fast pulse. All ADs so far have done that. I am trying a TCA now in a very low dose (nortriptyline), only two (2) mg. at night, but even that has me agitated. Dannen
Posted by Clayton on October 31, 2003, at 14:44:37
In reply to Re: Morning Depression - What worked well for me, posted by dannen on October 31, 2003, at 13:34:30
Pure speculation based on the experiences of my wife and general reading.
I assume benzos are not efficacious or counter-indicated for you. Xanax (maybe with Klonapin) is wonderful for depression and nervous aggitation.
Gabapentin (Nuurontin) can be efficacious in affecting general calming and stimulating your opiate system which can produce a sense of peace and well-being. It also affects the dopaineric system which can give you either a sense of unbothered tranquility or up your drive and aggitation, too. Dopagenergics are definitely antidepressants (though just try to find one that blocks it's reuptake directly. Ameneptine and nominifense have both been pulled from the market).
There is a lot of research (and some enlightening posts) on using opiates like ultram as direct antidepressant agents. For some it has worked.
And paradoxically, stimulants like Ritalin and Adderal reduce hyperactivity which might reduce aggitation.
Lastly, there has been some success at adjusting DOWN neurotransmitter levels instead of pumping them up. The best docs may attempt to balance their relative levels, too, while impacting the sensitivity of the receptors.
Too bad medicine is still in the dark ages on psyhciatric disorders. Just wait 200 years!
Forgive all the wild speculation but think about it and find a doc who might be competant (or lucky) at choosing the right combo of the above.
Good luck, bud.
Posted by obichoc on November 22, 2003, at 5:24:37
In reply to Re: Morning Depression - What worked well for me, posted by Clayton on October 31, 2003, at 14:44:37
I'm reading this thread and not seeing anything of how agitated depression may be the one and only symptom of several possible symptoms which may manifest itself in BPII. AD's for a BPII diagnosis are reportedly a no-no at the start of treatment becasue of the risk of INCREASING agitation; and logically may not be the best treatment if agitated depression is present as a symptom of undiagnosed BPII. For agitated depression as part of a BPII diagnosis, mood stabilizers such as Lamotrigine are apparently the treatment of choice. I'm new to this diagnosis (BPII manifesting as agitated depression) and am finding relief with Lamictal (lamotrigene) but as I write I'm dealing with considerable withdrawl symptoms from tapering on effexor which causes agitation apart from the BPII agitation. So the jury is out as to whether Lamictal is the answer for me, but I'm hopeful because when I hold on tapering of effexor for a bit and lessen that related agitation, I'm feeling much better..normal I'd say! I'm also 1 mg. klonopin and may taper on that after being off effexor for a while a. See more on this at: psychoeducation.org.
Posted by obichoc on November 22, 2003, at 5:30:26
In reply to Re: Morning Depression - What worked well for me, posted by obichoc on November 22, 2003, at 5:24:37
the addres for BP II is http://www.psycheducation.org/... not as shown on my post. sorry.
Posted by petalpusher54 on August 9, 2016, at 9:27:28
In reply to Re: Agitated depression; anxiety bad in morning, posted by dannen on October 23, 2003, at 18:51:39
> Zeugma. THANKS.
> I will be meeting with my pdoc in about an hour, and I will suggest nortriptyline. I hope I can tolerate it. I have been unable to tolerate anything so far (the SSRIs [agitation], Remeron [fast pulse], Wellbutrin [great agitation], Lamictal [agitation]). But I have never tried a TCA. I hope TCAs are different.
>
> I really appreciate the information and your kindness. God bless you.
>
> DannenDannen,
How did the nortripyline work for you? I have the same exact problem. Early morning anxiety, can't eat and by 6 pm feeling fine only to repeat the same thing the next day. Can't stand it any more can't tolerate most drugs make me extremely anxious. Have never used any Mao inhibitors. Please answer.....
petalpusher54
Posted by petalpusher54 on August 9, 2016, at 10:51:37
In reply to Agitated depression; anxiety bad in morning, posted by dannen on October 21, 2003, at 21:32:22
> I have been diagnosed with agitated depression. I have very bad anxiety in the morning. I wake up at about 5 am, with waves of anxiety. The anxiety is bad until about 8 am, and then it gets better through the morning and usually is gone by noon. Nights are fine. Then the cycle begins all over again.
>
> Does anyone else have this? What medication has helped? Nothing has worked for me yet. (Prozac, Zoloft, Paxil, Lexapro all caused great agitation.) Help.
>
> DannenDannen, Has the nortripyline helped? I have the exact symptoms as you have and have not done well on other meds please let me know how you are doing. petalpusher54
This is the end of the thread.
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