Psycho-Babble Medication Thread 64311

Shown: posts 1 to 9 of 9. This is the beginning of the thread.

 

Cam, I would really appreciate your insight

Posted by grapebubblegum on May 26, 2001, at 8:29:04

Please forgive me if you've read some of this elsewhere. I've cut and pasted my comments from other threads to try to crystallize the issue I'd like your insight on. You may recall that I was very confused by my doctor's occasional advice to take clonazepam .5 mg (or even .25 mg) three times per day vs. her alternating misgivings that I might get too dependent on that and need increasing dosages of it, and her advice to continue on SSRI's instead with clonazepam only prn:

A discussion elsewhere on the board and a link to the bearpaw page on panic disorder is inspiring me to open my mind to another approach to my struggle with this disorder. My doctor gives me some leeway to make lateral changes in my meds, i.e. adjusting the dosages of the meds (currently Paxil and Klonopin) she has prescribed. She believes that people need to get to know their own reactions to meds and does not discourage some tweaking thereof. In return, I keep her informed. I think she is pretty smart - how else can a patient and doctor really work out what is best for the patient with input only from the doctor? The patient has a valuable opinion in all of this, and has a viewpoint the doctor cannot fully tap into without the patient's interaction with his/her plan of treatment.

I have found in retrospect that the SSRIs may have been causing me more problems than I thought. I was up to a high dose of zoloft (200 mg per day) and STILL had breakthrough panic attacks for a while, plus, as soon as I went over 100 mg. of zoloft I had the feeling of music playing or conversations going around in my head (not delusional stuff, just the usual tune in your head but louder and more disruptive.) Then my legs were so restless I was stretching and flexing them all night, and while I did sleep, I had that half-asleep feeling all night.

When I switched to Paxil for the above reasons, I immediately noticed a return to better sleep. I was not restless, but if I did happen to awaken in the night, I'd have a feeling of, "I'll just stay up and play on the computer for an hour" which is NOT like me. Then when I recently cut my Paxil dose in half (down to 10 mg. per day - is that even therapeutic?) even BEFORE I got smart enough to add in the clonazepam, I noticed a return to truly restful sleep like I haven't had in six months. And besides getting my sexual function back, I am not craving carbs constantly or feeling half-rested all the time. It will take a lot to get me back on those SSRI's again. I'm not trying to badmouth them as much as I am just chronicling my own recent epiphany. I've been on and off them (more off than on) for the last ten years, and I've used four different kinds, and I can see that there really is value in them but I am starting to see now that maybe it was like using a sledgehammer to hammer in a poster brad. They served their purposes but I wonder if there was some overkill.

Currenly I'm ramping down the Paxil and taking very small amounts of Clonazepam (12.5 mg three times a day, believe it or not, has a strong beneficial effect on me). I can tell you that it took TWO DAYS ONLY of cutting my Paxil in half from 20 mg to 10 mg per day to restore my orgasmic function with my partner.

I am just so fed up with the various SSRI side effects. I wonder if my doc and I have been barking up the wrong tree by using them. Like I said, I don't consider myself "depressed" in the classic sense, or maybe not in any sense. That is a label that has always been ascribed to me, but it is often said that anyone suffering panic attacks will eventually seem depressed in the aftermath.

Cam, my basic question is: since there is a strong family history of bipolar disorder (my father and my son) do you think it's possible that my tendency toward very sporadic panic attacks represents something other than the classic depression that SSRIs are meant to treat, as I understand it? It's true that I've noticed some moderately challenging depression features in myself at times, including OCD thoughts (not actions), some obsessive self-blame and some interpersonal irritability that is relieved with SSRI treatment, (are these not all more anxiety than depressive features?) but I've never felt "depressed" as I understand the word to be defined. Now that I'm taking such small doses of Klonopin and very little Paxil, I've never felt better. (Yes, I get a little irritable with others but I think it's well within the realm of what's normal for humans.) Do you think the hype about dependency on benzodiazepines is overblown (I remember you said that tolerance does develop to clonazepam's sedative effects but not its anxiolytic effects and that is what spurred me to go ahead and try this. Sure enough, after only a week, the sedation is much less of a problem but I don't feel that familiar "aura" of a panic attack looming every evening like I used to before I started using the klonopin regularly.) I had not previously understood that klonopin doesn't reach peak concentration for four hours and this is why I thought that a three x per day regimen, as my doctor has suggested off and on (she waffles on it) might make sense.

Just looking for your thoughts, if you have any, on the subject of SSRIs vs. benzodiazepines, particularly the clonzepam-class ones, for panic disorder.

 

Re: Cam, I would really appreciate your insight » grapebubblegum

Posted by Cam W. on May 26, 2001, at 10:45:26

In reply to Cam, I would really appreciate your insight, posted by grapebubblegum on May 26, 2001, at 8:29:04

GBG - Love the name, but like your doctor even more. I have given a couple lectures on the subject of concordance (patient and doctor working together, incorporating each of their belief systems into an integrated whole). Throughout the history of medicine this approach has shown to work than most of the current therapies of the time. The Brits seem to have a lot of writing about this, starting about 25 years ago. The advent of HMOs (U.S.) and Medicentres (Canada), and the lure of the almighty dollar, seem to have really screwed up any chance of this becoming a commonplace reality in North America. My new doc, like yours, gives me some leeway in therapy and treatment, but has to rein me in every now and then (LOL). Keep this lady under your hat, or you may never be able to book appointments.

Panic disorder is thought to be a screw-up of the serotonergic neurons from the raphe nuclei (major source of serotonergic projections in the brain) to a structure enclosed under the hippocampus (can't remember which one - notes are at work and they won't let me have them while I'm on stress leave < shrug >). It seems that there is a lack serotonergic transmission in this pathway. It seems that this lack of serotonin is what panic disorder has in common with depression, OCD, PTSD, etc.; all involve a lack of serotonin in more or less different, but specific, serotonin pathways.

This is why SSRIs are used in panic disorder, as well as depression (and the other conditions). Doses for panic disorder are normally higher by 50% than are used in depression (eg. Paxil™ - paroxetine - doses of 30mg are normally used for panic disorder). Paxil is commonly used in panic disorder because of the antimuscarinic and anxiolytic actions of the drug. One unfortunate problem with the SSRIs being used in panic disorder is that the drugs make the panic worse for the first couple of weeks taking it.

What is going on in your case seems to be a little different than classic panic disorder. As stated above, because panic disorder involves the serotonergic system, it occurs quite frequently (comorbidly) with depression and OCD. I am going to take a guess at what is going on in your body, but remember, it is only a guess. Instead of being deficient in the amount of serotonin your body produces, you may a faulty subset of serotonin receptors (ie. only a partially functional 5-HT1A or 5-HT1B receptor) due to a genetic miscoding in your DNA. So, adding serotonin to your system doesn't really do anything to to these receptors but add side effects through your normally functioning subsets of serotonin serotonin receptors. This could be why SSRIs are ineffective for you and why they seem to making your situation worse.

As for benzodiazepines like Klonopin™ (clonazepam - Rivotril™ in Canada), it has been my experience that people who use them for a real reason (not to forget life &/or stay "high" - or is it low?) do not seem to overuse or abuse them. If anything, some people with bipolar disorder do not seem to use them enough. Seldom have I seen someone with bipolar disorder abuse benzodiazepines; it seems that they like the manic high over the artificial low of benzodiazepines. As for panic disorder, there is a little more concern for the overuse of these drugs. These people can panic at the thought of a panic attack and some will drug themselves into a semi-stupor to avoid an attack. If you are diligent about self-monitoring your use, use the lowest effective dose (hopefully .125mg - 3x daily and not the 12.5mg you wrote - LOL), and restrict increases to breakthrough panic attacks, there should really be no harm in long-term Klonopin use. If need be, keep a journal of your Klonopin use, so that you will be able to show your doc that you are not overusing it.

If you truly do have a defective gene for a subset of serotonin receptors, the only drugs that would be effective for you would be the benzodiazepines (perhaps a beta-blocker as well). Ask your doc about my theory and see what she has to say.

I hope that this is of some help. - Cam

 

Re: Cam, I would really appreciate insight ..Gil

Posted by gilbert on May 26, 2001, at 12:10:07

In reply to Re: Cam, I would really appreciate your insight » grapebubblegum, posted by Cam W. on May 26, 2001, at 10:45:26

Cam,

I am in the same boat as grapebubblegum. I have not had good luck with the ssris even at very low doses prozac at 5mg. celexa at 10mg. I have had bad side efects. I tried buspar 2 years ago and was so dizzy I could not walk almost like serotonin overload. I am beginning to believe that the serotonin connectiion is not for me although I do exhibit some OCD tendencies which would suggest otherwise. I have had great success with the xanax no panics in 2 years. I am curious though about the long term effects of xanax especially on prolactin and cortisol levels....does 1mg per xanax per day effect these levels greatly. I would also like to try st johns wort but am not sure if thes would help with my flat mood which is a result of the xanax use. I thought maybe I could augment the xanax with something natural to offset the only bad side effect of this drug some mild depression........I am done trying to get the ssris to work kind of like fitting square peg in a round hole.....

Gil

 

Re: Cam, I would really appreciate insight ..Gil » gilbert

Posted by Cam W. on May 26, 2001, at 12:42:37

In reply to Re: Cam, I would really appreciate insight ..Gil, posted by gilbert on May 26, 2001, at 12:10:07

Gil - I am the wrong guy to ask about cortisol and prolactin, as I am a community pharmacist and have never really been a hospital (clinical) pharamacist, except out of necessity. Perhaps Sunnely could help you here. I have never heard of long-term problems with prolactin nor cortisol levels with benzodiazepines.

That being said, Xanax™ (alprazolam) is slightly different from other benzodiazepines in that it has weak (possibly transient) antidepressant activity due to it's strong binding to a subtype of GABA receptor. This could lead to a lowering of the elevated cortisol levels seen in depression.

As for using SJW, you may run into similar problems that you are with the SSRIs. Then again, a trial of a month or two couldn't really hurt at this point (except to your wallet). If you do try SJW, do use a standardized, recognized brand like Kira™ or Perikya (sp?). Have you considered non-SSRI antidepressants? It may be something to talk to your doctor about, but a word of caution, drugs like Wellbutrin™ (bupropion), Norpramin (desipramine) or reboxetine (which probably won't get approved anyway) could theoretically may the OCD symptoms worse. You may be in a similar situation as I mentioned to GrapeBG, where a subset of serotonin receptor genes is faulty (perhaps a different subset than GBG), rather than having a deficiency of serotonin.

Another option would be to fine tune the Xanax dose slightly downward to see if the blunting stops. That happy medium is sometimes hard to attain.

The last option would be to try a different benzodiazepine like Klonopin™ (clonazepam), Serax™ (oxazepam) or even Valium™ (diazepam), although Xanax is the benzodiazepine of choice for acute panic attacks. Still, I find Xanax to be too short acting for many people for a maintenance drug for panic disorder. I like Xanax more for breakthrough episodes of panic and use a longer acting benzo (like Klonopin) for maintenance.

I hope that you get something out of this wishy-washy answer. - Cam

 

Re: Cam, I would really appreciate insight ..Gil

Posted by grapebubblegum on May 26, 2001, at 15:37:34

In reply to Re: Cam, I would really appreciate insight ..Gil » gilbert, posted by Cam W. on May 26, 2001, at 12:42:37

Your answers are not wishy-washy at all, Cam, and I really appreciate your time and trouble. You are right that my Dr. is a total gem, as she practices at home by herself and she knows she is one of the last of a dying breed, and the current trends in mental health care management are not impressive to her (or to me.)

If you can stand one last question: the possible faulty subset of serotonin receptor genes that you mentioned to me and Gilbert... do you know if this is more often associated with bipolar depression than with unipolar, and do you know whether panic disorder is more often associated with bipolor or unipolar? It came as a surprise to me several years ago to learn that panic disorder and depression are frequently comorbid, and I had always thought that, going further, bipolar disorder was a totally different animal than depression/panic disorder. Is bipolar disorder just depression with a side order of mania thrown in for kicks? My guess is that the biological origin of the disorders would be totally different, and I am wondering also if the panic disorder follows one more than the other. I know that my father, a definite bipolar, suffered from panic attacks but I don't think he was aware of the name for them or aware that they were a specific "condition." All this has changed so much in the last several decades. I know I am annoyingly curious, but if you understand the genetic or biological origins or similarities/differences between these three conditions I would appreciate picking your brain just a little more.

And yes (LOL) I meant .125, not 12.5. I am very curious as to how some people can tolerate many milligrams of that stuff, or NEED it for their seizures, yet .5 mg will have me passed out under the table.

 

Cam-Another question about Klonopin

Posted by AnneL on May 26, 2001, at 21:10:55

In reply to Re: Cam, I would really appreciate insight ..Gil, posted by grapebubblegum on May 26, 2001, at 15:37:34

Hi Cam,
Hope you don't mind another question on Klonopin.
I have been on Effexor XR for 3 months for depression. Current dose 150 mg. daily with a plan to titrate up slowly. I had several negative experiences with SSRI's in the past and always had a panic response so I was prescribed Xanax to be used prn in order to get past the initial side effects/anxiety. Within 1 week I started getting rebound anxiety, I was only on 0.25 mg at nighttime and found the panic attacks so extreme at night that I was needing more Xanax, usually within one or 2 hours of the first dose. So my doctor prescribed Klonopin due to its longer action. I have taken 1 mg. of Klonopin (clonazepam) at night for roughly 3 months, have no cravings or desires for it at other times of the day and sleep beautifully. I am concerned about coming off the Klonopin from the postings on this board and my own knowledge about benzodiazepines in general. Last week I reduced my dose from 1 mg. to 0.5 mg. to see if I could get the same quality of sleep and woke up at least 10 times during the night and generally felt pretty awful in the morning. Would it be advisable to slowly cut back on the Klonopin or should I follow my instinct which tells me, "if its not broke, don't fix it"? I worry about my dependence (if only psychological) on this medication to help me sleep through the night undisturbed by anxiety or insomnia. By the way is talking in one's sleep a side effect of the Effexor or the Klonopin? My husband tells me I have quite a few "conversations" every night. No nightmares or vivid dreams, thank goodness, but I wonder if I would even remember them anyway? I believe that the Klonopin is quite a short term amnesiac, at least for me. Thanks for your input.
AnneL

 

Re: Cam, I would really appreciate insight » grapebubblegum

Posted by Cam W. on May 26, 2001, at 23:53:51

In reply to Re: Cam, I would really appreciate insight ..Gil, posted by grapebubblegum on May 26, 2001, at 15:37:34

GBG - I have no information on my receptor theory because it is just an angle that I had thought of to explain the SSRI sensitivity. I am not sure that is what is really going on. Also, as to the associations, I cannot give firm answers about that, as my information is at work and I can't get at it for another month or so.

I do believe that depression and bipolar disorder are separate syndromes, with different physiochemical mechanisms that manifest as similar disoders (ie. the depression phase of bipolar looks like major depression, but there are probably significant differences between the two).

I would also hazard a guess that panic disorder is comorbid with major depression, but this could only be because major depression is more prevalent than bipolar disorder. I really have no firm answers on any of this, though.

Sorry I cannot be of more help. I am more comfortable with my knowledge of the drugs, rather than the disease states. - Cam


 

Re: Cam-Another question about Klonopin » AnneL

Posted by Cam W. on May 27, 2001, at 0:04:00

In reply to Cam-Another question about Klonopin, posted by AnneL on May 26, 2001, at 21:10:55

Anne - You are still taking a low dose of Klonopin™ (clonazepam) and there should be no problem continuing. This is a question to ask your doc, as he/she will have a much better grasp on your condition than I could. You may get some sort of psychological dependence over the long-term, but as long as you are not increasing the dose or begin to use the Klonopin as a coping mechanism, there should be little problem.

You could ask your doc about using 50mg to 100mg of Desyrel™ (trazodone) as this drug does not have the same properties as the benzodiazepines. Desyrel is a non-addicting, but very sedating antidepressant in the same family as Serzone™ (nefazodone). If you are truly worried about dependence, this drug is a safe and viable alternative to the benzodiazepines. One problem is that it has no anti-anxiety activity. If this is required you may need to stay on the Klonopin.

Serotonergic antidepressants seem to cause talking in the sleep. The Effexor™ (venlafaxine) has serotonergic properties like the SSRIs and I would think that this is the primary culpert. The Klonopin could be adding to this by relaxing you and allowing you to carry on the conversation. And yes, the Klonopin can cause amnesia of the event.

Hope this helps - Cam

 

Re: Cam-Another question about Klonopin » Cam W.

Posted by AnneL on May 27, 2001, at 0:30:32

In reply to Re: Cam-Another question about Klonopin » AnneL, posted by Cam W. on May 27, 2001, at 0:04:00

> Anne - You are still taking a low dose of Klonopin™ (clonazepam) and there should be no problem continuing. This is a question to ask your doc, as he/she will have a much better grasp on your condition than I could. You may get some sort of psychological dependence over the long-term, but as long as you are not increasing the dose or begin to use the Klonopin as a coping mechanism, there should be little problem.
>
> You could ask your doc about using 50mg to 100mg of Desyrel™ (trazodone) as this drug does not have the same properties as the benzodiazepines. Desyrel is a non-addicting, but very sedating antidepressant in the same family as Serzone™ (nefazodone). If you are truly worried about dependence, this drug is a safe and viable alternative to the benzodiazepines. One problem is that it has no anti-anxiety activity. If this is required you may need to stay on the Klonopin.
>
> Serotonergic antidepressants seem to cause talking in the sleep. The Effexor™ (venlafaxine) has serotonergic properties like the SSRIs and I would think that this is the primary culpert. The Klonopin could be adding to this by relaxing you and allowing you to carry on the conversation. And yes, the Klonopin can cause amnesia of the event.
>
> Hope this helps - Cam

Yes, this helps greatly. Thank you for your thoughtful response. I will speak to my pdoc about the possibility of crossing over to trazadone at some point. However, upon reflection, I am greatful for the relief that I have experienced so far and don't want to "rock the boat" so to speak. I'll take things slowly and revisit this in time. Thanks again, your input and knowledge is truly appreciated!


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