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Dr. Bob is Robert Hsiung, MD,
bob@dr-bob.orgShown: posts 1 to 12 of 12. This is the beginning of the thread.
Posted by zeugma on April 30, 2004, at 18:17:58
I started taking klonopin in November after the total failure of six months of CBT to alleviate in any way my debilitating symptoms of social anxiety/avoidant personality disorder. Klonopin at low dose has alleviated the drastic anxiety somewhat, but at the cost of some side effects of its own (increased fatigue, sleep disruption) and I hardly feel like my anxiety is in a satisfactory state. It also may in small degree contribute to depression (not sure). Or maybe I'm just having a relapse because of stress.
In any case, I just got off the phone with my therapist. I said to her that maybe I need a new antidepressant, one that has more efficacy in anxiety, and she said she'd been thinking the same thing. I said I'd been considering Anafranil. She sounded shocked and said that was a "hard one to take" (referring to side effects) and suggested lexapro instead. I said that Lex wouldn't help me sleep, unlike Anafranil, which is quite sedating (I currently take nortriptyline which, in conjunction with buspirone, has given me the first sustained relief from insomnia in my life.) She said that if I added lexapro, I could keep the nortriptyline and drop the buspirone (four is my limit for psychotropics, and besides 75 mg nortriptyline, .5 mg Klonopin (qd) and 30 mg buspirone I also take 80 mg Strattera for ADD).
My idea was that I could slowly mix the Anafranil in with the nortriptyline, maybe taking 25 mg Anafranil along with the nortrip to see how i tolerated it. I know tricyclics can be harsh at first but nortriptyline has always agreed with me and SSRI's haven't. Anafranil could then replace the nortriptyline if it went over ok, and i could have the sedative benefits of the TCA plus the serotonergetic effect of Anafranil on social phobia/AvPD/depression. Plus I would be taking one less drug (I'm planning on dropping the buspirone too, whichever alternative I choose. If and when gepirone ER comes out, I might try that, but I am skeptical thait will offer much of an improvement on the existing drug.) Anafranil or Lexapro? Comments please.
Posted by zeugma on April 30, 2004, at 21:41:18
In reply to which plan sounds more reasonable, posted by zeugma on April 30, 2004, at 18:17:58
the symptom i am trying to target is fear, or more specifically the response patterns that have built up over the years as a result of having my amygdala constantly activated. i think the best thing for this kind of problem would be an maoi, but adding a 5-HT reuptake inhibitor to Klonopin and the NE reupatke inhibitors should be a step in the right direction. i am determined to solve this problem. it's making my life miserable.
Posted by chemist on May 1, 2004, at 0:14:54
In reply to Re: which plan sounds more reasonable, posted by zeugma on April 30, 2004, at 21:41:18
> the symptom i am trying to target is fear, or more specifically the response patterns that have built up over the years as a result of having my amygdala constantly activated. i think the best thing for this kind of problem would be an maoi, but adding a 5-HT reuptake inhibitor to Klonopin and the NE reupatke inhibitors should be a step in the right direction. i am determined to solve this problem. it's making my life miserable.
chemist here...are you considering an MAOI and an SSRI? AVOID. if you are unipolar depession, and can adhere to the MAO diet, then do so. otherwise, go with a more activating ssri (effexor, e.g.) and stay with klonopin. but DO NOT take and MAOI and an SSRI concurrently....all the best, chemist
Posted by Sad Panda on May 1, 2004, at 3:57:52
In reply to which plan sounds more reasonable, posted by zeugma on April 30, 2004, at 18:17:58
Hi Zeugma,
I'd try cross tapering to Clomipramine from Nortriptyline since it's the easiest thing to do & probably the best drug that isn't a MAOI. If it is a failure, it should be easy to go back to Nortriptlyline and then try adding an SSRI or Effexor or even an MAOI to it. Imipramine is another TCA worth trying, but it lacks the potent 5-HT2A blockade that most of the TCA's have which I would consider to be an important part of their anxiolytic & good sleep effect.
Downsides to Clomipramine are that it will have roughly double the strength/mg of side effects and half the antihistamie sedation.
Cheers,
Panda.
Posted by zeugma on May 1, 2004, at 5:22:55
In reply to Re: which plan sounds more reasonable » zeugma, posted by chemist on May 1, 2004, at 0:14:54
> > the symptom i am trying to target is fear, or more specifically the response patterns that have built up over the years as a result of having my amygdala constantly activated. i think the best thing for this kind of problem would be an maoi, but adding a 5-HT reuptake inhibitor to Klonopin and the NE reupatke inhibitors should be a step in the right direction. i am determined to solve this problem. it's making my life miserable.
>
> chemist here...are you considering an MAOI and an SSRI? AVOID. if you are unipolar depession, and can adhere to the MAO diet, then do so. otherwise, go with a more activating ssri (effexor, e.g.) and stay with klonopin. but DO NOT take and MAOI and an SSRI concurrently....all the best, chemistI'm not considering an SSRI and a MAOI concurrently. I may not have been entirely clear in my post. What I meant was that MAOI's seem to be the best treatment for depression with severe social anxiety, but that my dr. is unlikely to let me try one until I've tried some kind of 5-HT reuptake inhibitor (I have tried some but not under his care). Also, Strattera and MAOI's are officially contraindicated, although it would seem that if some TCA's can be safely taken with an MAOI, then so could Strattera.
I think I could stick to the MAOI diet (I hate cheese!). But before I try it, I want to try either Lexapro or clomipramine, since I wouldn't have to go through a washout period, and if it falls I would have more leverage with my dr. to let me try the MAOI. I hope the selegilene patch comes out soon.
Posted by zeugma on May 1, 2004, at 5:37:28
In reply to Re: which plan sounds more reasonable » zeugma, posted by Sad Panda on May 1, 2004, at 3:57:52
> Hi Zeugma,
>
> I'd try cross tapering to Clomipramine from Nortriptyline since it's the easiest thing to do & probably the best drug that isn't a MAOI. If it is a failure, it should be easy to go back to Nortriptlyline and then try adding an SSRI or Effexor or even an MAOI to it. Imipramine is another TCA worth trying, but it lacks the potent 5-HT2A blockade that most of the TCA's have which I would consider to be an important part of their anxiolytic & good sleep effect.
>
> Downsides to Clomipramine are that it will have roughly double the strength/mg of side effects and half the antihistamie sedation.
>
> Cheers,
> Panda.
>Yes, I was thinking that one advantage would be the ease of tapering from nortriptyline to clomipramine. I also thought of imipramine (and amitriptyline), but I have not seen any reports that they might offer a substantially stronger anxiolytic effect than nortriptyline. I have a feeling though that my dr. may be more willing to prescribe lexapro. I didn't know that clomipramine was only half as sedating as nortriptyline. That is something to keep in mind.
Posted by Keith Talent on May 3, 2004, at 6:11:31
In reply to Re: which plan sounds more reasonable, posted by zeugma on May 1, 2004, at 5:37:28
Why are you taking nortriptyline if you're taking atomoxetine (Strattera)? They both work by blocking the noradrenaline transporter, only atomoxetine is more potent. Do you need the histamine-1 antagonistic effect of nortriptyline for sleep? You'd be better off taking Ambien or triazolam (Halcion) for sleep. By the way, clomipramine (and its metabolite desmethylclomipramine) kick nortriptyline's and atomoxetine's butts re noradrenaline reuptake inhibition. Sounds to me like you could drastically rationalise your medication regimen. I'd either go for:
clomipramine
clonazepam
Ambien or triazolamor
an SSRI
atomoxetine
clonazepam
Ambien or triazolamClomipramine has a reputation as being an EXTREMELY powerful antidepressant, but my psychiatrist said that it doesn't sedate at all (and I agree, having taken it).
Posted by zeugma on May 3, 2004, at 16:14:23
In reply to Re: which plan sounds more reasonable, posted by Keith Talent on May 3, 2004, at 6:11:31
> Why are you taking nortriptyline if you're taking atomoxetine (Strattera)? They both work by blocking the noradrenaline transporter, only atomoxetine is more potent. Do you need the histamine-1 antagonistic effect of nortriptyline for sleep? You'd be better off taking Ambien or triazolam (Halcion) for sleep. By the way, clomipramine (and its metabolite desmethylclomipramine) kick nortriptyline's and atomoxetine's butts re noradrenaline reuptake inhibition. Sounds to me like you could drastically rationalise your medication regimen. I'd either go for:
>
> clomipramine
> clonazepam
> Ambien or triazolam
>
> or
>
> an SSRI
> atomoxetine
> clonazepam
> Ambien or triazolam
>
> Clomipramine has a reputation as being an EXTREMELY powerful antidepressant, but my psychiatrist said that it doesn't sedate at all (and I agree, having taken it).I am as nonplussed as you are (maybe more, seeing as I'm the one taking these things) by the redundancy of my medication regimen. In part it's a quirk of med approval history: when I went to my current pdoc, I was off meds (and doing miserably) and needed something to help my inattentive ADD and depression symptoms. Atomoxetine hadn't been approved in the US yet, and nortriptyline had demonstrated some efficacy (less than desipramine) in ADD, besides being a tolerable antidepressant. And yes, the H-1 blockade helped me to sleep, though for some reason it works much better when I take 15 mg buspirone about 3 hours after my nortriptyline dose (it potentiates the sedative effects).
75 mg nortriptyline was enough to relieve my depressive symptoms, but I was still suffering severely from ADD, and being severely underweight (people who see me routinely wonder if I have an eating disorder) I can't take stimulants, because every time I have taken ANY stimulant in the past I have been yanked right off two weeks into treatment, because the weight-loss effect on my already emaciated frame is so sudeen and dramatic. So my pdoc added atomoxetine, and somehow, it worked: I was finally able to obtain, and more importantly, to keep, full-time employment (somehow atomoxetine cut into the fog enough to function). I have to hypothesize that i have massive noradrenergic dysfunction if I can tolerate 75 mg nortriptyline plus 80 mg atomoxetine. i don't know. I want to rationalize my treatment by getting rid at least of some of the redundancy. If clomipramine is more energizing than nortriptyline, that would be a good thing, because I am fatigued all the time. what I am wondering is if atomoxetine has any special potency re inattentive ADD, apart from its NE reuptake blocking properties which it shares with TCA's and other drugs. In any case, I feel that my present regimen has my ADD under control, but my anxiety, and anxiety-induced depression, isn't. I've raised the clonazepam to .75 mg, but while it helps with some aspects of anxiety, it doesn't give me any energy or desire to socialize, and doesn't help the frquent dysphoria I feel due to my social inhibition (and I feel pretty sure that a higher dose wouldn't help either, although it would be helpful in other ways). How do you find clomipramine compares with other TCA's (I assume you've taken a few?) How is its s/e profile, compared to other TCA's and SSRI's? I think that by trading in the nortriptyline, I would at least make a start at streamlining my meds. To make it more rational still, I suppose I should raise my atomoxetine dose to 120 mg, add some Lexapro, take about 1 mg clonazepam and maybe some buspirone for sleep. How does that sound?
Posted by zeugma on May 3, 2004, at 16:36:11
In reply to Re: which plan sounds more reasonable, posted by zeugma on May 3, 2004, at 16:14:23
i also have narcoleptic-like symptoms, and atomoxetine does a better job than nortriptyline of keeping these under control. The kind of insomnia I have is related to going into REM while still partially awake, then suddenly waking fully less than a minute later. These symptoms are actuallyblocked by NE reuptake inhibitors, and atomoxetine is much more powerful than nartriptyline in this regard. So if I took 80 mg in the morning (as I do now) and 40 mg at night, it might solve my insomnia problem combined with the quasi-sedative buspirone (very short-acting, has a sedating effect maybe 20 minutes in duration which is sufficient to get me asleep, since i usually have no problems staying asleep if I can get past the first couple of minutes of sleep. Weird, I know, but it's been like that for me since I was in my early 20's.) Lex and Strattera and much cleaner drugs than nortriptyline or clomipramine, so maybe my pdoc would like the idea more, although I would be going way over the recommended 1.2-1.8 mg/kg guideline for Strattera. I have the feeling, though, that this regimen would leave me with much less fatigue than my current one.
Posted by Keith Talent on May 3, 2004, at 22:36:58
In reply to Re: which plan sounds more reasonable, posted by zeugma on May 3, 2004, at 16:14:23
>the H-1 blockade helped me to sleep, though for some reason it works much better when I take 15 mg buspirone about 3 hours after my nortriptyline dose (it potentiates the sedative effects).
This is messy - you have the potential here for more drug-drug interactions and more side effects than you should.
> being severely underweight (people who see me routinely wonder if I have an eating disorder) I can't take stimulants, because every time I have taken ANY stimulant in the past I have been yanked right off two weeks into treatment, because the weight-loss effect on my already emaciated frame
I don't know if you have time, with work committments and all, but could you pump some iron (and take a stimulant instead of atomoxetine)?
> if I can tolerate 75 mg nortriptyline plus 80 mg atomoxetine.
Because the atomoxetine competes much more effectively than nortriptyline for the same target (the noradrenaline transporter), the nortriptyline is doing nothing at that target for you. It is giving you some sedation via h-1 antagonism.
> If clomipramine is more energizing than nortriptyline,
If you're the kind of person who finds noradrenergic antidepressants energising, then I suppose you would find clomipramine that way.
> because I am fatigued all the time.
People on this board have complained that atomoxetine made them fatigued.
> wondering is if atomoxetine has any special potency re inattentive ADD, apart from its NE reuptake blocking properties
The noradrenaline transporter in the higher centres of the brain (frontal/prefrontal cortex) "vacuums" up dopamine as well as noradrenaline - but only in these higher centres. It is believed that this is why atomoxetine causes improved focus/concentration, but does not cause psychomotor stimulation. The latter needs a drug which acts directly on dopamine transporters in lower brain centres (which the amphetamines and methylphenidate do). To my very limited knowledge, this would be the only way that atomoxetine would have any "special potency" for inattentive ADHD.
> anxiety, and anxiety-induced depression, isn't. I've raised the clonazepam to .75 mg
This is still a very low dose.
> but while it helps with some aspects of anxiety, it doesn't give me any energy or desire to socialize, and doesn't help the frquent dysphoria I feel due to my social inhibition
A lot of posters here with Social Phobia swear by a combination of clonazepam plus either dextroamphetamine or mixed amphetamine salts (Adderall). Seeing as you have ADHD, it might be worth enduring the weight loss.
> How do you find clomipramine compares with other TCA's (I assume you've taken a few?)
Oh, I've taken a few: doxepin, clomipramine, amitriptyline, and nortriptyline. Doxepin, in my view, shouldn't ever be used as an antidepressant - it's basically an antihistamine (also used in allergy creams). Amitriptyline has a problem: its number one target is the histamine-1 receptor, meaning that no matter how much you take, you'll never get as much noradrenaline- and serotonin-transporter blocking as histamine-1 blocking (though not quite as bad as doxepin). All the early studies in the sixties were done with this and imipramine. I wouldn't bother with it. Nortriptyline did nothing for me, but it works for others, such as yourself. I would have gone on desipramine, except it's not available anymore in Oz (it's stronger than nortriptyline at the target that matters). Clomipramine was, for me, the best drug ever; however, I couldn't have orgasms and my resting heart rate was 110. Life's such a compromise, right? So I went back to Zoloft, and am about to get clonazepam and dextroamphetamine added.
> I think that by trading in the nortriptyline, I would at least make a start at streamlining my meds.
This is very important. The older we get, the more drugs get added (for things like blood pressure and cholesterol). The potential for interactions and side effects increases approximately exponentially with the number of drugs we are on.
> maybe some buspirone for sleep.
Isn't that for anxiety? I would have thought (depending on your insurance coverage) that temazepam, Ambien or triazolam would be better. Best of luck, buddy.
Posted by Sad Panda on May 4, 2004, at 13:05:44
In reply to Re: which plan sounds more reasonable, posted by Keith Talent on May 3, 2004, at 6:11:31
> Why are you taking nortriptyline if you're taking atomoxetine (Strattera)? They both work by blocking the noradrenaline transporter, only atomoxetine is more potent. Do you need the histamine-1 antagonistic effect of nortriptyline for sleep? You'd be better off taking Ambien or triazolam (Halcion) for sleep.
>
>Do you think Benzo style drugs are the way to go for sleep?
>
> By the way, clomipramine (and its metabolite desmethylclomipramine) kick nortriptyline's and atomoxetine's butts re noradrenaline reuptake inhibition.
>
>
>Actually desmethyl-clomipramine, nortriptyline, & desipramine are all similar in strength as NRI's, they differ in a similar way to their parent drugs.
Cheers,
Panda.
Posted by zeugma on May 4, 2004, at 17:29:41
In reply to Re: which plan sounds more reasonable » Keith Talent, posted by Sad Panda on May 4, 2004, at 13:05:44
> > Why are you taking nortriptyline if you're taking atomoxetine (Strattera)? They both work by blocking the noradrenaline transporter, only atomoxetine is more potent. Do you need the histamine-1 antagonistic effect of nortriptyline for sleep? You'd be better off taking Ambien or triazolam (Halcion) for sleep.
> >
> >
>
> Do you think Benzo style drugs are the way to go for sleep?
I think clomipramine would sedate me enough to sleep, and would be better than a benzo for this purpose. But obviously I am speculating about the sedative properties of clomipramine. What i actually need more urgently is relief of anxiety/depression than insomnia.
>
> >
> > By the way, clomipramine (and its metabolite desmethylclomipramine) kick nortriptyline's and atomoxetine's butts re noradrenaline reuptake inhibition.
> >
> >
> >
>
> Actually desmethyl-clomipramine, nortriptyline, & desipramine are all similar in strength as NRI's, they differ in a similar way to their parent drugs.Desipramine is a much more powerful NRI than nortriptyline; at least four times more powerful, and probably more. I don't know what the figures are for desmethylclomipramine but it probably has a higher potency for both 5-HT and NE transporters than nortriptyline. And it has a longer half life than atomoxetine, which is only about 5 hours.
I'm going to ask my pdoc to let me try a 25mg capsule of clomipramine with my two 25's of nortriptyline, and gradually taper from one to the other (as per my original plan last week). He hates dispensing benzodiazepines, but does not seem averse to TCA's, so i am hoping he will let me try my little experiment. The idea of adding Lexapro becomes less appealing with the thought that it might make dropping the nortriptyline more difficult, plus the SSRI's offer fewer opportunities for slow titration.
>
> Cheers,
> Panda.Thanks to you both,
z
>
>
This is the end of the thread.
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