Posted by Elizabeth on June 27, 2001, at 10:31:20
In reply to Re: benzos, posted by paulk on June 26, 2001, at 16:18:19
> >“They do have other effects in addition to MAO inhibition, though: Nardil is also an inhibitor of GABA metabolism, while Parnate is *thought* to have some sort of dopaminergic effect (perhaps induction of dopamine release: Parnate is chemically extremely similar to amphetamine).
>
> !@# Lawyers – I sure wish that information had been in the PDR. –Lawyers? Quoi?
> The Nardil has just kicked in in the last week or so – I still question that the low BP is caused by other than the increase in the monoamines – from what I understood until 90% of the MAO is knocked out There isn’t enough rise in neuro transmitters to do anything.
No, the increase in neurotransmitter concentrations takes place immediately. That's not directly responsible for the antidepressant effect of the drug, but a lot of the side effects, direct or indirect, happen sooner, orthostatic hypotension being one of these. MAOIs (and tricyclics) decrease the compensatory cardiovascular response to changes in posture.
> I seem to be doing OK except I am starting to have trouble with word selection – and sometimes the wrong word will come out.
That's a common effect of antidepressants, especially tricyclics and MAOIs. Anticholinergic drugs are the worst that way, but norepinephrine has some effects that oppose those of acetylcholine. MAOIs upset the reciprocal interaction between NE and ACh; as a result, they virtually abolish REM sleep. In light of this, their effects on implicit or associative memory are surprisingly subtle.
> I wonder if it is a side effect of the GABA?
In the case of Nardil, that might have something to do with it too. (I had the word-finding problems on Parnate as well, although it wasn't a big deal with any of the MAOIs.)
> Perhaps I should take the med at night?
I tried taking Nardil on every imaginable dosing schedule. Didn't make any difference in any of the side effects.
> I am still at the high dose 60/mg day – perhaps it will get better when they lower the does back down.
I don't think that's such a good idea. First of all, 60 mg is *not* a "high" dose; it's a normal dose. Also, although it was once thought that the right way to give people antidepressants was to start with a high "loading" dose and then decrease it down to a very low "maintenance" dose, this has proven not to work very well. (My own experience with MAOIs bears this out: at one point I tried decreasing the Nardil to 30 mg, and my depression and panic started coming back. I've also tried dropping the Parnate down to 30, 20, and even 10 mg, and it just doesn't work very well when I do that.)
> Was the inhibition of the GABA metabolism a direct effect of the drug or secondary?
I'm still not sure what you mean by that (although I know what *I* would mean < g >). I'm also not sure the mechanism is known. But I believe it's an early effect, not one that takes a week or more to happen.
On to the benzos....
> He was taking – I think it was Restaril – (sp??) . He was very bi-polar yet a dear friend – very smart – didn’t usually go psychotic in his mania. He really needed to be in a halfway house to have someone monitor is medications. The lack of supervision is what I blame for his death. I think the benzos may have surpressed his gag reflex or dis-coordinated his swallowing enough to cause the problem.
It's really horrible to think about this, but the fact is, people with serious mental illness who don't have family to take care of them are at high risk of death for a whole lot of reasons. For example, a person with bipolar disorder, especially one who has trouble functioning to the point where he needs to live in a halfway house, is pretty much guaranteed to be on a lot of medications, possibly including neuroleptics (and perhaps anticholinergics to offset the side effects), lithium, and/or anticonvulsants. All of these have known risks, some of which can be quite serious. Bipolar disorder is associated with a high risk of suicide attempts and substance abuse as well.
Restoril (temazepam) is generally prescribed only for insomnia, not for daytime anxiety. It is unlikely that your friend was prescribed this medication in very large doses.
> I don’t think this would be a common problem with people who can manage there own meds.
Well, it isn't. It also isn't a common problem with benzodiazepines in general. The other medications used to treat bipolar disorder are much more dangerous. A lot of times I hear of people dying from polydrug overdoses, but some particular drug (usually a controlled substance) is singled out as the cause. When someone dies from an overdose of benzos and alcohol, it's not because benzos are dangerous or toxic. If either drug by itself is to blame in such a case, it's the alcohol -- an incredibly toxic drug (several characteristics of ethanol make me want to label it a solvent rather than a drug, and it certainly has no place for systemic use in modern medicine).
> Most of these people were in the hospital because they had benzo problems – sort of self-selected. Remember everyone reacts differently.
Fair enough. But I bet that most of those people abused other drugs, not just benzos. I've known a few people who abused benzos, but without exception they were addicted to alcohol or heroin and abused other drugs (cocaine, amphetamines). Addicts sometimes use benzos to substitute for their DOCs when supply is short, and they can easily become dependent because they tend to self-medicate (i.e., take the benzos in an unsupervised fashion) with very large doses (some people apparently can get high on benzos, but I've never known anybody who could get high on the usual prescribed doses!).
[re withdrawal symptoms:]
> It sure does it to me. – That’s why I’m interested in the slow release version.Well, remember, slow release doesn't mean slow elimination. A lot of people have a hard time getting off of Effexor XR, for example. Xanax SR would be great for people who need to take it every day, though.
> I would take it for anxiety and it worked – wonderfully – but then as it wore off I would feel even worse than before.
I guess I'm confused. What sort of anxiety were you taking it for? (Any diagnosis?)
> I didn’t use Xanex after the prescription ran out because of that problem – I didn’t get addicted – but I sure wanted to keep taking more and more, but realized I shouldn’t.
"Wanting" to take increasing doses of a drug is always a good sign that you're headed for addiction, yes.
> I really liked and hated the drug. Sure wish I could try the XR version.
If you're going to take it for a while and then stop, it's still going to cause withdrawal symptoms. I don't know about this rebound anxiety that you speak of, because I don't think I've ever heard of that before even with regular Xanax.
> I would say that irritability is a symptom of anxiety??
I guess it depends on your definition. I usually think of anxiety as involving inhibition, and irritability as involving disinhibition.
However you want to slice it, the people who have these weird reactions to Xanax (I looked into it, and some of them seemed to involve self-injury in people with a history of cutting, etc.) are people who have problems with emotion regulation. Sometimes that looks a lot like anxiety (presumably that's how they got prescribed Xanax in the first place).
> The irritability wasn't there until the drug was wearing off. You might be forgetting the wide variation of how these drugs effect people. (YMMV grin).
I'm not forgetting. I've known dozens of people who took benzos, mostly Xanax and Klonopin. None of them ever had this problem. Some people experience irritability or peevishness during benzo withdrawal, but that's after discontinuing chronic use.
Did this "rebound anxiety" happen the very first time you took Xanax? And how often were you taking it? (Frequent use, even if it's not around-the-clock, can lead to some degree of dependence.)
> I know the nasty discontinuation effects of Effexor – yet for many folks they can stop cold with out any problem.
Yeah, I didn't have a problem stopping it, but I'd only been on it for a month or so. (Plus, I had to stop because of a rather nasty reaction, so even if I had withdrawal symptoms I might not have noticed them!)
> CWSP = Cold Wet Sheet Packs – THE non-drug treatment for anxiety. (I wouldn’t want it done to me – its not fun to watch – but it seems to work a bit.
Remind me never to submit to "inpatient detox." < g >
> I’m thinking that there needs to be a new specialty in medicine – an endroconologist/pycopharmacologist. It sure would be nice if there were better and objective tests that could show what drugs to try first. – perhaps spinal fluid tests or long term urine collection for cortisal tests?
Oh, that would be great, but reliable tests of the type you're talking about (even those involving lumbar puncture, which, BTW, is not a practical test to do routinely) just don't exist, with few exceptions (the dexamethasone suppression test can be used to determine which depressed patients are potential candidates for steroid-suppression therapy; urinary levels of the norepinephrine metabolite MHPG are pretty consistently elevated in depressed patients who respond to alprazolam).
> Reminds me – I ran into yet another old friend who tried Effexor – told me he went sort of manic (couldn’t sleep – roofed a house all night long in the dark) – his doc now thinks he may be a bit bipolar.
Not conclusively by any means. Unipolar depressives -- no family history of bipolar disorder, no personal history of mania or hypomania, and no subsequent spontaneous manias or hypomanias -- can sometimes have this kind of reaction to antidepressants. It's idiosyncratic, but not unheard of. Some people are sensitive to a particular AD or class of ADs, and some ADs have a greater tendency than others to trigger mania. (Tricyclics have a particularly bad reputation for this, and my pdoc says he thinks Effexor is a bit worse than the other new-generation ADs.)
-elizabeth
poster:Elizabeth
thread:65795
URL: http://www.dr-bob.org/babble/20010625/msgs/68067.html