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Dr. Bob is Robert Hsiung, MD,
bob@dr-bob.orgShown: posts 1 to 8 of 8. This is the beginning of the thread.
Posted by BusuB on October 14, 2014, at 12:50:37
So as the title says, I've been having a lot of trouble for the past year and a half finding a medication that will adequately control my generalized anxiety and depression. Since February of 2013 I've been trialing medications. So far I've tried each of the following: escitalopram, venlafaxine, clomipramine, fluoxetine, duloxetine, vortioxetine and now citalopram. Each medication trial was at minimum 8 weeks (up to 6 months on escitalopram). However, each one except for clomipramine causes me to have terrible early morning insomnia and an inner restlessness that can only be described as mild akathisia that can vary in intensity day to day. They've all differed in mild ways, for instance on fluoxetine, I'd wake up trembling and mild panic, with citalopram, I wake up with extreme restlessness in legs and arms. My health anxiety and general worry about external things are under control but I find myself focusing on how I feel quite a lot. Bottom line I just feel extremely uncomfortable in my body with these antidepressants. I'm on week 8 of citalopram right now (week 5 of current dose of 20) and I'm ready to throw in the towel.
Is there a reasonable explanation for why I feel this way on antidepressants? I have tried med free between vortioxetine and citalopram but quickly found that I need something to control my worry and depression (about 6 weeks post withdrawal I was bawling in my docs office). Back to clomipramine, just made me extremely fatigued, constipated and numbed my genitals the whole time I was on it. Some restlessness but not as extreme.
Posted by ed_uk2010 on October 14, 2014, at 16:34:27
In reply to Bad reactions to all antidepressants?, posted by BusuB on October 14, 2014, at 12:50:37
Have you tried an antidepressant with a completely different mechanism of action, eg. mirtazapine? That would seem like a sensible first-choice if you've not already tried it. Mirtazapine can cause drowsiness and sometimes weight gain. Serious side effects are rare.
All the meds you've tried already are potent serotonin reuptake inhibitors. Some people develop physical restlessness on all SRIs, and do better on ADs which lack this property, on share it only to a minor extent.
Also, have you tried a less sedating, less-serotonergic tricyclic instead of clomipramine? Nortriptyline might be a good choice... if not, imipramine might help. Among the TCAs, genital numbing is only likely with clomipramine.
Finally, is your diagnosis major depression rather than something else such as bipolar disorder. That would affect treatment choice.
Posted by BusuB on October 14, 2014, at 17:39:14
In reply to Re: Bad reactions to all antidepressants?, posted by ed_uk2010 on October 14, 2014, at 16:34:27
Thanks for the response Ed. My primary dx(es) are GAD and Panic Disorder. I have had 1 MD episode about 5 years ago when I first started getting panic attacks. I was successfully treated with paroxetine 5 years ago, then moved to sertraline when my anxiety symptoms relapsed (and the paroxetine didn't work as well). I was good on sertraline for about 12 months before it started to give me this restless response that I'm now sharing with all SRI's. I have asked my pdoc about the possibility of bipolar but was given an emphatic no to that possibility.
Mirtazapine was in the back of my head as a possibility as well as it tends to lack the boner kill traits of the SRI's, but am worried that the NASSA's would give me a similar reaction (restlessness/anxiety) as from what I understand it simultaneously increases serotonin production while inhibiting reuptake (please correct me if I'm wrong).
I have tried nortriptyline as a sleep aid when I was on fluoxetine (10mg), but never as monotherapy. I understand it's a much stronger NRI vs SRI, but after my experience with clomipramine I was a little put off. Is it much easier to adjust to than the clomipramine?
Posted by Phillipa on October 14, 2014, at 18:03:42
In reply to Re: Bad reactions to all antidepressants? » ed_uk2010, posted by BusuB on October 14, 2014, at 17:39:14
Xanax for panic attacks. Works like a charm. Phillipa
Posted by BusuB on October 14, 2014, at 18:16:36
In reply to Re: Bad reactions to all antidepressants? » BusuB, posted by Phillipa on October 14, 2014, at 18:03:42
Agreed Phillipa, I'm actually okay with occasional panic, but it's the generalized anxiety that really gets my goat.
Long term benzo use, unfortunately for me, leaves me dysphoric and hungover.
Posted by Christ_empowered on October 16, 2014, at 7:01:09
In reply to Re: Bad reactions to all antidepressants?, posted by BusuB on October 14, 2014, at 18:16:36
neurontin? lyrica?
Posted by SLS on October 16, 2014, at 8:34:19
In reply to Re: Bad reactions to all antidepressants? » ed_uk2010, posted by BusuB on October 14, 2014, at 17:39:14
Have you tried imipramine? It is a tricyclic antidepressant for which there is a great deal of evidence as being effective in treating Panic Disorder with or without agoraphobia. Nortriptyine, desipramine, and clomipramine are said to be effecive, too, but have not been studied as thoroughly. At least on study showed clomipramine to be more effective than imipramine. Most people find the anti-cholinergic/pro-adrenergic side effects of tricyclics to be problematic, but you might find them tolerable. These effects are milder with nortriptyline and desipramine, but I don't know how they compare to imipramine therapeutically. The blood levels of imipramine found to be effective are between 110-140 ng/ml. Desipramine might be the logical choice, though, if serotoninergic effects are the cause of your intolerance of other antidepressants. Desipramine is the major active metabolite of imipramine, and is devoid of serotonin reuptake inhibition.
- Scott
Posted by SLS on October 16, 2014, at 8:40:57
In reply to Re: Bad reactions to all antidepressants?, posted by BusuB on October 14, 2014, at 18:16:36
> Agreed Phillipa, I'm actually okay with occasional panic, but it's the generalized anxiety that really gets my goat.
Nardil (phenelzine)? I have seen it produce robust improvements in someone who had GAD + PD.
- Scott
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