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Re: amoxapine for social phobia 3 Beer Effect

Posted by Elizabeth on December 28, 2001, at 13:31:11

In reply to Asendin (amoxapine)? Also my 2 cents about doctors, posted by 3 Beer Effect on December 19, 2001, at 3:47:37

Hi. It's not all that unusual for people with social anxiety to get in trouble with alcohol and other drugs (which drugs did you have problems with, BTW?). What is unusual is for social phobics to be treated with tricyclics. It's pretty well known that the response rate to TCAs in social phobia is much lower than the response rate to MAOIs. I believe that for patients with social phobia (with or without comorbid depression or panic disorder) or atypical depression, MAOIs should generally be tried before TCAs and that TCAs should be considered a last resort.

I tried amoxapine once -- with Parnate -- and found I couldn't tolerate it once I got up to 75 mg/day. I had the same experience with nortriptyline and it's turned out I probably don't metabolize TCAs normally (due to an enzyme deficiency). The side effects I recall were vivid dreams, constipation, dry mouth, and appetite stimulation -- mainly anticholinergic and antihistaminic side effects. I don't know why, but all the TCAs I've tried (as well as some of the antipsychotics, Risperdal in particular) have given me vivid and sometimes unpleasant dreams. This isn't due to the histaminic or cholinergic receptor blockade, I don't think. Anyway, you should probably find it more tolerable assuming you're a normal metabolizer. If you have trouble with low doses, you might try getting your serum level checked -- if you're like me, a low dose might be all you need to get a therapeutic serum level.

Amoxapine is a somewhat unusual TCA in that it has dopamine antagonist (i.e., antipsychotic) effects as well as the usual TCA effects (NE reuptake inhibition and antagonism at various receptors), but I wouldn't expect it to be any more effective than the rest of them for social phobia or atypical depression. It might be worth it for you to try it, but I think MAOIs would be a better choice if you haven't tried them already and if you've had no success with newer ADs (SSRIs, Effexor, etc.).

I don't recommend arguing with the doctor, but I do think that he owes you an explanation for why he's trying a tricyclic for someone with social phobia and why amoxapine in particular. Amoxapine is less likely than the old antipsychotic drugs to cause extrapyramidal reactions (movement disorders), but all antipsychotics available today carry this risk to some degree and I don't think antipsychotic drugs should be used unless they definitely help the person (they do help many people who aren't psychotic, BTW). If the doctor things you need an antipsychotic, IMO he should try an antipsychotic (one of the newer ones like Geodon or Seroquel, preferably).

It also sounds like you need to emphasize that the social anxiety is the thing that you really need to get treated for. Unfortunately, addiction specialists seem to be even more likely than the average pdoc to consider benzos "out of the question." I think that a lot of this idea that benzos are "addictive" comes from a misunderstanding of what "addiction" is -- people, even doctors, believe that withdrawal symptoms upon discontinuing a drug are evidence that a person is "addicted" to it. (See, for example, Guinnee Pig's post.) It's been well established that anxiety patients treated with benzodiazepines almost never abuse their medication, and often take *less* than the prescribed amount, not more. (I don't know if there's any research specifically on patients with anxiety disorders and histories of substance abuse. This would be interesting. My prediction is that patients receiving adequate treatment (i.e., an effective dose) would not abuse the benzos, especially if slow-acting benzos like clonazepam were used.)

It might help if you can get the doctors to understand that your substance abuse was an attempt at self-medication. Another thing you might try would be to dig up some of the research on benzos (Klonopin is the best tested one, probably) for social phobia and present it to your doctors -- the researchers used much higher doses than what you're getting now. Some people do okay on as little as 0.5 mg/day, but others need quite a bit more. (Some people also need to take it 3 times a day to achieve the maximum benefit.) Here are a few references:

Davidson JR, Potts N, Richichi E, Krishnan R, Ford SM, Smith R, Wilson WH. Treatment of social phobia with clonazepam and placebo. J Clin Psychopharmacol 1993 Dec;13(6):423-8.

Davidson JR, Ford SM, Smith RD, Potts NL. Long-term treatment of social phobia with clonazepam. J Clin Psychiatry 1991 Nov;52 Suppl:16-20.

Reiter SR, Pollack MH, Rosenbaum JF, Cohen LS. Clonazepam for the treatment of social phobia. J Clin Psychiatry 1990 Nov;51(11):470-2.

Ontiveros A, Fontaine R. Social phobia and clonazepam. Can J Psychiatry 1990 Jun;35(5):439-41.

Best of luck to you in getting the help you need. I know it can be really hard once you've been labelled a "drug abuser," but don't give up hope.

-elizabeth


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