Psycho-Babble Medication Thread 3603

Shown: posts 1 to 11 of 11. This is the beginning of the thread.

 

Insomnia, Vivid dreams, reboxetine & efexor

Posted by Nick on March 11, 1999, at 14:03:46

Does anyone have any advice about managing insomnia/vivid dreams in patients with major depression whose mood has returned to normal? Nefazadone and mirtazapine ineffective; any help/suggestions gratefully received - I'd rather avoid benzo's if possible. Thanks, Nick.

 

Re: Insomnia, Vivid dreams, reboxetine & efexor

Posted by Julzzz on March 11, 1999, at 17:27:57

In reply to Insomnia, Vivid dreams, reboxetine & efexor, posted by Nick on March 11, 1999, at 14:03:46

> Nick, When did the insomnia & vivid dreams start? Before or after the medication? Julzzz

 

Re: Insomnia, Vivid dreams, reboxetine & efexor

Posted by Elizabeth on March 13, 1999, at 10:36:57

In reply to Insomnia, Vivid dreams, reboxetine & efexor, posted by Nick on March 11, 1999, at 14:03:46

> Does anyone have any advice about managing insomnia/vivid dreams in patients with major depression whose mood has returned to normal? Nefazadone and mirtazapine ineffective; any help/suggestions gratefully received - I'd rather avoid benzo's if possible. Thanks, Nick.

Clonidine might work. Are you taking any antidepressants now? If not, how recently did you discontinue them and which one(s)?

 

Re: Insomnia, Vivid dreams, reboxetine & efexor

Posted by Nick on March 14, 1999, at 13:39:26

In reply to Re: Insomnia, Vivid dreams, reboxetine & efexor, posted by Julzzz on March 11, 1999, at 17:27:57

> > Nick, When did the insomnia & vivid dreams start? Before or after the medication? Julzzz

These were treatment-emergent side effects, not stigmata of depression. They usually start within a short time (days) of treatment commencing, and do not improve parallel to improvements in mood, interest or energy. Sometimes they lead to dropout from treatment.

 

Re: Insomnia, Vivid dreams, reboxetine & efexor

Posted by Nick on March 14, 1999, at 13:44:13

In reply to Re: Insomnia, Vivid dreams, reboxetine & efexor, posted by Elizabeth on March 13, 1999, at 10:36:57

> > Does anyone have any advice about managing insomnia/vivid dreams in patients with major depression whose mood has returned to normal? Nefazadone and mirtazapine ineffective; any help/suggestions gratefully received - I'd rather avoid benzo's if possible. Thanks, Nick.
>
> Clonidine might work. Are you taking any antidepressants now? If not, how recently did you discontinue them and which one(s)?

The problems are in those I prescribe for. I've had a lot of success using venlafaxine & reboxetine, but have found the sleep disturbance a persistent problem. I've never used clonidine, and wondered about the usually effective dosage and timing of dose. By the way, thanks to you & Julzzz for taking the time to post. Cheers, Nick.

 

Re: Insomnia, Vivid dreams, reboxetine & efexor

Posted by Elizabeth on March 17, 1999, at 22:11:42

In reply to Re: Insomnia, Vivid dreams, reboxetine & efexor, posted by Nick on March 14, 1999, at 13:44:13

Hi Nick. I'd suggest clonidine, then. It's often used for children with ADHD, along with Ritalin, to help them sleep (also helps with "frustration tolerance" problems). I'm not sure how I feel about using a cardiovascular drug on kids, but it should be fine for adults. Check interactions with the antidepressants of course. It might be especially good for anxious, labile patients. The minimum dose strength is 0.1mg; I'd start there but don't hesitate to increase to 0.3mg or possibly more (not sure what the maximum is). Side effects are usually mild, may cause a little dry mouth and orthostatic hypotension.

A tricyclic might work, but it has the risk of excessive side effects. I notice you're in the UK: is lofepramine a sedating drug? That would be my first choice if it is (and indeed, I often wish we had it here in the States). Well, anyway, if lofepramine isn't sedating, imipramine or nortriptyline would be fine. A good conservative dose to start on would be 25mg, increase as necessary (within safe limits of course :-) ).

Another thing I've heard of to block vivid dreams or nightmares is valproate, a fairly large dose (start with 500mg and titrate up) taken at bedtime. If you Brits have gabapentin, that's another sedating anticonvulsant with fewer side effects that might work as well.

Any of these can be taken an hour or so before bedtime.

Hope this helps.

-Elizabeth

 

Re: Insomnia, Vivid dreams, reboxetine & efexor

Posted by nick on March 21, 1999, at 15:11:27

In reply to Re: Insomnia, Vivid dreams, reboxetine & efexor, posted by Elizabeth on March 17, 1999, at 22:11:42

Dear Elizabeth

Many thanks for taking the time to help me out. I'd actually taken the plunge this week & started clonidine 0.1 mg in a patient with A/D induced sleep disturbance and a patient with PTSD (markedly intrusive symptoms, rather than avoidant)Unfortunately, psychopharmacology is not taught in any structured way beyond a very basic level in the UK even to specialists, and I am always keen to learn new strategies.

Lofepramine is a relatively NA specific MARI, with reduced antihistaminergic & anticholinergic potential in comparison with the older drugs. Its not very sedative. I accept your point about tricyclics as adjunctive medication but that seems culturally foreign to me, as they are regarded as a 'bad thing'. Hmmmmm. Thanks once again & cheers, Nick

 

Re: Insomnia, Vivid dreams, reboxetine & efexor

Posted by Elizabeth on March 24, 1999, at 14:17:23

In reply to Re: Insomnia, Vivid dreams, reboxetine & efexor, posted by nick on March 21, 1999, at 15:11:27

> Many thanks for taking the time to help me out. I'd actually taken the plunge this week & started clonidine 0.1 mg in a patient with A/D induced sleep disturbance and a patient with PTSD (markedly intrusive symptoms, rather than avoidant)

Hey, sure! I hope it works out.

>Unfortunately, psychopharmacology is not taught in any structured way beyond a very basic level in the UK even to specialists, and I am always keen to learn new strategies.

That seems to be the way a lot of it is done here (U.S.) as well - the exchange of anecdotes! Pretty scary, I think. (Even as I sit here participating in it.)

> Lofepramine is a relatively NA specific MARI, with reduced antihistaminergic & anticholinergic potential in comparison with the older drugs. Its not very sedative.

That's too bad; I'd heard of it as a "kinder, gentler" tricyclic and thought it might offer some help here.

>I accept your point about tricyclics as adjunctive medication but that seems culturally foreign to me, as they are regarded as a 'bad thing'.

They're not used so much here anymore, either, but recently the combination of SSRI (usually Prozac) + low-dose desipramine has gotten - uh, trendy :-) - if the SSRI by itself does not help enough.

 

Re: Other combinations

Posted by Nick on March 24, 1999, at 15:10:40

In reply to Re: Insomnia, Vivid dreams, reboxetine & efexor, posted by Elizabeth on March 24, 1999, at 14:17:23


> They're not used so much here anymore, either, but recently the combination of SSRI (usually Prozac) + low-dose desipramine has gotten - uh, trendy :-) - if the SSRI by itself does not help enough.

Interesting - the main metabolite of lofepramine is desipramine; desipramine is no longer in use here because of cardiotoxicity, yet lofepramine is pretty safe in overdose. Go figure. Other 'heroic' combinations include nefazadone + venlafaxine (I think Steven Stahl uses this one) + the old favourites of TCA + MAOI (ouch). Some evidence for buspirone + SSRIs & pindolol + SSRIs. Its a complicated world.

 

Re: Other combinations

Posted by Elizabeth on March 28, 1999, at 2:13:48

In reply to Re: Other combinations, posted by Nick on March 24, 1999, at 15:10:40

> Interesting - the main metabolite of lofepramine is desipramine; desipramine is no longer in use here because of cardiotoxicity, yet lofepramine is pretty safe in overdose. Go figure.

I didn't know that lofepramine is metabolized to desipramine! Go figure, indeed. (Desipramine is the most used of the tricyclics here because it has fewer side effects than the other ones we have.)

>Other 'heroic' combinations include nefazadone + venlafaxine (I think Steven Stahl uses this one) + the old favourites of TCA + MAOI (ouch). Some evidence for buspirone + SSRIs & pindolol + SSRIs. Its a complicated world.

Yeah, I've heard of some strange ones - SSRI + pretty much anything except an MAOI, or even two SSRIs together, TCA + MAOI (rumor hath it the tricyclic may provide some resistance to MAOI-induced hypertension), etc. I don't hear of pindolol being used so much; buspirone, valproate, olanzapine and risperidone, and old standbys like lithium seem to be the favored augmentation drugs. Also, bupropion gets added to just about anything including MAOIs.

Ever used reboxetine in combinations? I'm surprised I don't hear more about that.

 

Re: Other combinations

Posted by Nick on March 30, 1999, at 14:47:13

In reply to Re: Other combinations, posted by Elizabeth on March 28, 1999, at 2:13:48

>
> Ever used reboxetine in combinations? I'm surprised I don't hear more about that.

It's still pretty new, and quite frankly there isn't that much published on it - usual stuff vs imipramine, fluoxetine, but nothing as yet on augmentation. I would imagine that standard strategies used to augment TCAs woould be safe.


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