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Re: Adding Klonopin to the mix and therapy

Posted by JohnL on November 18, 2000, at 6:08:05

In reply to Adding Klonopin to the mix and therapy, posted by dove on November 17, 2000, at 11:56:50

> My p-doc added Klonopin to my med cocktail yesterday. He believes it will help smooth out my continued ultra-rapid cycling, smother my panic attacks, soothe my anxieties, and keep my depression above the death-awaiting line.
> Current med cocktail:
> Adderall (20mgs am, 10mgs noonish, 10mgs early evening)
> Amitriptyline (Elavil, 200mgs before bed)
> Serzone (Nefazodone, 100mgs am, noon, pm, bedtime)
> Neurontin (Gabapentin, 2,400 mgs spread throughout my waking hours)
> Klonopin (Clonazepam, 0.5mgs x3 per day (1.5 mg total), dosage to be increased in three weeks)
I sure empathize with you. I'm not sure anything I can comment on will be of any help, but I'll share my thoughts just in case. You can consider them or discard them at your discretion.

My favorite pdoc, now retired, kept records of what medicines achieved excellent results in his patients. Dr Jensen does the same thing. I was surprised to see how closely the records of both match each other. They only differ by a few percentage points. Anyway, here is a chart of which drugs got excellent results in what percent of patients in the anxiety/panic group:
Antidepressants 48% of patients got excellent results (37% were serotonin ADs)
Benzodiazepines 24%
Lithium 22%
Stimulants 14%
Antipsychotics 13%
Depakote 11%
Tegretol 3%
Lamictal 0%
Neurontin 0%
Thyroid 24% (if tests were borderline or a family history was present)
Stimulants often required a small dose antipsychotic addition to reverse anxiety or phsychosis.
Beta adrenergic blockers were not recorded but were helpful, mostly with palpitations.

Three comments on this chart. First, many of these things that actually got excellent results have no clinical justification for treating anxiety/panic. But they worked. That's important as I see it. Lithium for example. Who would have ever thought? Second, when the correct medicine was found, the patients usually not only experienced excellent results, but they experienced rapid results in anywhere from one day to three weeks. The longer a drug took to work, the less likely it was to eventually give excellent results. Third, if 47% of patients got excellent results with antidepressants, well that means 53% didn't. You could perhaps be in that 53% group. Otherwise I would think Serzone and/or Amitriptyline would be giving better results than they are.

With all this in mind, one has to wonder if any of your current meds are really the correct ones? Klonopin is I think a fine choice for two reasons. First, it is a benzo, it is commonly used to treat anxiety/panic, and according to the chart it has one of the highest statistical probabilites of working well. Second, it is also a mood stabilizer, which differentiates itself from other benzos. So it theoretically has the potential to benefit your panic and your cycling simultaneously. Also, in a clinical trial a 3mg dose was shown to accelerate the response to an SSRI, with major improvement noticed in one week. Of course, as a disclaimer, this med can actually worsen symptoms in a small subset of patients, but in that respect so can any other med.

With Adderall in the mix, I am very tempted to point to antipsychotics.

When all is said and done, and the dust has settled, it wouldn't surprise me at all if your cocktail ended up being something like Klonopin + Adderall + small dose Zyprexa or Risperdal, with none of the other current meds. If a fourth med were included, my guess based simply on the chart would be either Lithium or Depakote.

Again, I empathize with you. There's a lot to think about and consider. Though I think Klopopin is an excellent move, I also question the role of the other meds. Though they may be helping somewhat, they are obviously not providing excellent results, and that logically indicates they are probably not the correct meds. I think when the correct meds are tried, you will eventually find your cocktail includes fewer drugs yet with greater benefits. Hopefully Klonopin will lead in that direction. Antipsychotics and/or Lithium/Depakote/Tegretol could be considered to replace the other current meds.

Hope something here might be helpful. It's a tough one, no question about it.

ps...As to therapy, it's well established that medicine+therapy is more effective than either alone. Mostly what I've heard is that therapy can provide effective techniques to control panic episodes, but can't cure them. Being able to take of control of them, rather than them taking control of you, is the usual goal in panic therapy. I've never heard of anyone being cured of panic in therapy. They learn how to manage it. I could be wrong, but I feel panic such as yours is an organic chemistry phenomenon. If that's true, then therapy could indeed help manage panic episodes, but not cure them. The correct medicine that fixes whatever chemistry is awry is what will eventually cure it completely. Until that happens though, I would think therapy would be helpful in learning coping techniques to get yourself through the tough moments as smoothly as possible.




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