Posted by Rick on July 5, 2001, at 1:54:47
In reply to Re: One more try - Klonopin and Wellbutrin » Rick, posted by Joe Schmoe on July 4, 2001, at 19:44:16
> > I trust your doc is going s-l-o-w working you up to the 300.
>
> My schedule is a 150 SR tablet once a day for three days, then two 150 SR tablets per day after that. I took my first one about 7 hours ago, so far I feel a little euphoric but with some tightness in my chest. I used it as motivation to go exercise.“Exercise”...The more I hear that word, the better. Maybe I’ll finally get off my butt and get serious about doing it.
> >If you have the opportunity to first try the Klonopin solo for awhile, that would be a good because within a week or less you should have a sense of whether it's working out for your SP (which I fully expect).
>
> Well I have taken a few days off work so I decided to get the Wellbutrin going so I can get the worst parts of it out of the way. No way to test the Klonopin at home for SP....although I may end up taking it anyway just to test drive it and help with any Wellbutrin jitters.The jitteriness I experienced with Wellbutrin was pretty much low-level and inconsequential when I was by myself or with someone I’m close to. But it was magnified in situations that triggered social phobic reactions. During those times, the benefits of the Klonopin would be reduced, e.g., I’d tense up some, speak less, and sound kind of nervous and shaky when I did get myself to speak up. Note that I’m talking in relative terms here...even with some renewed social anxiety, I was still a lot better off than pre-Klonopin.
I think your idea of using the time off to get accustomed to the Wellbutrin is a good one, especially if you do want to follow “doctor’s orders” on the quick ramp-up. There’s a good chance that this will work out well for you. But that’s still a pretty fast ramp-up of an activating AD for someone with social phobia, so don’t be caught off guard if you find yourself more anxious than you expected during your first “SP-challenge” situations, even with Klonopin. Things could go just great; or they could start out iffy but improve as you adjust; or you could end up needed to re-assess (e.g., try backing down on the Wellbutrin for awhile or, if that doesn’t help, add more Klonopin to offset the Wellbutrin activation). Again, I’m not saying to *expect* any problem, but just be prepared to realize that some kind of further adjustment could very well be necessary with this kind of combo in SP.
BTW, with my own brand of SP, it would be easy to test things when I’m not at work. Things like ordering a pizza, talking to a postal clerk, or picking up a prescription could make my heart beat fast and my voice tremble. Never had any problem at grocery stores, though, which seems to be a common problem for a lot of socially anxious people. Go figure. (A prescription pick-up incident was especially bad on my second day of Celexa. In fact, the Celexa almost completely wiped out Klonopin’s benefits for me from days 2-6 after appearing to help on day 1. For a few days I was worried that the Klonopin had pooped out. But that worry didn’t last long.)
> >Of course if you experience pretty severe depression, it may be best to start ramping up on the AD right away.
>
> I would say I am more dysthymic. It comes and goes. I have never spent days in bed or anything like that, but I have a pretty negative outlook on life most of the time along with hopelessness at times.
>
> >(My pdoc actually suggested starting at 25 mg and moving up slowly...I should have followed his advice. I felt no adverse effect at 50mg, so I made the mistake of jumping up to 100 mg too quick.)
>
> You must have been taking the non-SR version then? The smallest SR pill is a 100 mg I believe. And you are not supposed to divide it or it will ruin the SR properties. There is nothing I can do with these 150 mg pills except take them whole. My doc was out of samples, I wonder if the sample pacs have smaller doses for SR?
>
Nope, it was SR. He suggested original Wellbutrin, but I asked for Wellbutrin SR. My pdoc wrote the prescription for 100 mg once a day, saying that a pharmicist would have a fit if handed a script for 25 mg./day Wellbutrin. Even though he’s a very non-conservative pdoc on many ways (e.g., major fan of MAOI’s and says the food restrictions are way overstated), he’s a big start-low-go-slow proponent, especially for anxiety. Plus, he had seen how low-dose dopamine-selective selegiline had made me nervous; was taking into account that this was being added to another AD (Celexa); and wanted to be cautious on the seizure front. (Not sure why on the latter. Maybe because of the mild in-bed body jerks I had with Nardil and the intense in-bed body jerks I had from 1 day of lithium augmentation of selegiline. I don’t understand much about extrapyri-whatever side effects.)I did in fact find it odd that he was suggesting splitting an S-R tablet, into quarters no less. But he insisted that this was OK to do. And I *have* seen others post that their docs said the same thing. (For the record, though, there are a number of areas where I don’t think he knows what he’s talking about. Even though he’s NOT benzophobic, he never even wanted me to try Klonopin, and I had to really had to do the full-court press to get him to prescribe then-unfamiliar Provigil instead of Ritalin. He later thanked me for turning him on to the anxiety-fighting properties of low-dose Provigil, which he’s now used successfully in some treatment-resistant cases of GAD and depression.)
> >And there are definitely anxious people who do well with it once they get used to it, although there should usually be something of a more calming nature in the mix -- in your case, Klonopin.
>
> I usually don't suffer from free floating anxiety. I am not sure if I am considered an "anxious person" or not, since my anxiety is almost always caused by some obvious external factor, i.e. social scrutiny, worrying about some upcoming confrontation or performance, etc. If there is nothing wrong in my life, I feel fine and can go months without Xanax. That is why I think of myself more as "sensitive" and prone to catastrophic overreaction to problems, rather than anxious. Probably why I was always given Xanax instead of Klonopin. Of course Xanax is only useful if you get advanced warning...."These people just showed up, can you give them a little presentation about our organization?" "Sure....*gulp*"That’s why I prefer daily Klonopin, so that it’s steady state. Not for general anxiety (although I’m sometimes a worrier, even with Klonopin), but so I don’t have to worry about come-as-they-may social situations. Sometimes, if a presentation, big meeting, or social event is coming up, I’ll rearrange my dosing schedule a bit (NEVER dosing less than four hours apart, though) and/or add .25 mg extra K, or .5 on rare occasions.
I frankly don’t think as-needed is optimal, but it should still be a big help. Besides, it sounds as if you plan to try out a daily .5 mg morning regimen, anyway. That sounds like a good compromise approach.
>
> > BTW, you mentioned the size of your Klonopin pills, but not the daily dosage. Does this mean you're taking it as-needed?
>
> Yes, she wants me to figure out what I will need. Due to my past experience with xanax I am still reluctant to take a benzo round the clock for fear of developing tolerance. I will try to get away with taking it on weekday mornings and see if that works. I am afraid even that will cause a tolerance/dependance to develop but at this point who cares, I want a better life.
>
> I guess my fear is building a tolerance, having to up the dose, repeat, etc. till I am at the maximum dose and what do you do then when you develop a tolerance? I wish I knew how often I could take it and still avoid a tolerance.Certainly some people can develop benzo tolerance, but that seems to be the exception to the rule when the benzos are used responsibly. (E.g., see attached study abstract for Klonopin in panic disorder). I’ve slowly been reducing the amount of Klonopin I take all along, with no intention whatsover of tapering off of it completely at this point. I started at 3 mg/day which helped a good deal, but quickly found that 1.5-2.0 helped a lot more while almost completely eliminating any sedation. I’ve been at 1.25 mg. for many months, and last week went to 1.0 (and then from 450 to 300 on the Serzone). After an iffy start, it seems to be working out OK, but I can’t say for sure yet. On Psycho-Babble I see a lot fewer complaints about poop-out in posts on benzos than I do in posts about ADs or other psychotropics.
>
> > Good luck to you. I think you've got a real good chance of doing well with this combo for both your depression and your SP, especially if you start-low-go-slow with the Wellbutrin.
>
> Thanks. Wellbutrin seems to have a lot of positive commentary compared to the other ADs. I was scared away from it by the seizures thing, but on closer examination, it seems to have the same seizure rate as Paxil and Zoloft. I don't understand what is going on. I will start a new thread on this.Yes, again that’s one area where I think my pdoc’s knowledge was behind the times. From everything I’ve read, with SR the seizure rate is about the same as with other AD’s. I’ve also heard lots of great things about Wellbutrin for depression, and specifically for dysthmia, too. My friend’s sister started it about two months ago (her first prescription psychotropic ever), and she’s thrilled with how much better she feels, apparently without side effects. BTW, her GP was going to give her Serzone – and this is a woman who has had three accidents in the last year from falling asleep at the wheel! If anyone needed an activating AD rather than a sedating one, she was it. (Although I suppose one could argue that nighttime-only dosing with Serzone could help her sleep through the all-night barking of the dogs she breeds.) So I had my friend arm her with some literature on Wellbutrin, and her GP prescribed that instead.
1: Psychopharmacol Bull 1998;34(2):199-205 Books
Long-term experience with clonazepam in patients with a primary diagnosis of panic disorder.Worthington JJ 3rd, Pollack MH, Otto MW, McLean RY, Moroz G, Rosenbaum JF.
Department of Psychiatry, Massachusetts General Hospital, Boston 02114-3117, USA.
This study examined the use patterns and efficacy of the high potency benzodiazepine (HPB) clonazepam in panic patients who were treated and followed naturalistically in the Massachusetts General Hospital Longitudinal Study of Panic Disorder. Of 204 patients followed over a 2-year period, 46 percent were receiving clonazepam alone or in combination with an antidepressant. Treatment was not controlled at initial evaluation or during the followup period. The main variables assessed in this analysis included global severity of the panic disorder and stability of clonazepam dose. All treatment groups tended to improve over time without significant differences in outcome between groups. Clonazepam doses remained stable over time. Results of this study suggest that treatment of panic disorder with the HPB clonazepam achieved and maintained a therapeutic benefit similar to that obtained with alternative pharmacologic treatments, without the development of tolerance as manifested by dose escalation or worsening of clinical status.
poster:Rick
thread:68599
URL: http://www.dr-bob.org/babble/20010701/msgs/69015.html