Advice for an antidepressant needed

[Gene53]

Hi,

After being "overly nervous and anxious" most of my life, I was finally diagnosed with Chronic Anxiety Disorder, Panic Disorder, PTSD and other CNS disorders 12 years ago and after trying all kinds of meds, my ex-physician and I concluded that Rivotril (clonazepam, 1mg twice/day) was the most successful one at keeping me on an even keel.

Due to some events which have been happening for the past few years, I slowly sunk into depression and for the past year, severe depression.

I've finally coaxed myself to see a psychologist and he suggested I also get a prescription for an antidepressant (plus psychotherapy) but I'm quite aware that clonazepam doesn't jive too well with other meds.

Any advice on compatible meds would be appreciated.

Thanks,
Gene

 

[braveheart]

I don't know about compatible meds, but I'm on mirtazapine for similar problems. [I have depression as well.] Others've been on efexor for such diagnoses, but it didn't work out for me, mainly because I needed a sedating anti-depressant.

 

[Into The Light]

you did really well going to a psychologist. that's the first step, and not easy when depressed! :goodjob:

with regard to medication, i don't know too much about that. i think your best bet would be to see your doctor about this, or get a referral to a psychiatrist who is specialized in these medications. i am sure there must be some med combination out there that will work.

 

[Retired]

The selection of an appropriate medication can only be made by your physician.

Based on your medical history, along with family medical and medication history, along with your physician's clinical experience, your physician may have a medication regimen to propose.

No one on the internet can make a diagnosis and recommend medications reliably and especially ethically.

but I'm quite aware that clonazepam doesn't jive too well with other meds.

Specifically what are your concerns about clonazepam?

 

[David Baxter PhD]

There's not usually a problem being on an SSRI and clonazepam at the same time. Many of my clients take both.

 

[Gene53]

you did really well going to a psychologist. that's the first step, and not easy when depressed!

How right you are, I started thinking about seeing one more than 6 months ago but procrastinated till I just couldn't take it any more. I've been cooped up for so long (went out only once since January) that I almost flipped-out (anxiety attack) about an hour before the appointment.

i am sure there must be some med combination out there that will work

Sure hope so, everything I looked at on the net left me confused more than anything else.

Specifically what are your concerns about clonazepam?

After being on this for over 12 years, I'm afraid I'm starting to feel the side-effects more than it's benefits. The first 7 years were OK then we had to increase the dosage from 1mg to 2mg/daily due to tolerance to the med and it wasn't working as well as it did.

When this med was working well, I used to take half a tablet in the morning and the other half before going to bed. Before the depression set in, the morning dosage would make me feel a little "woozy" 30 to 45 minutes after taking it but this feeling only lasted about 20 minutes or so.

But, for the past 8 months or so, I've been feeling more side effects and those uncomfortable feelings lasted for over an hour and for the past 6 weeks, even worse. It starts off with dizziness and tiredness (kind of like a 'hangover' effect), after an hour or two I feel irritable, restless, tremors, muscle cramps, tense, etc. and frequently builds up to an anxiety attack. I also have difficulty sleeping (frequent insomnia), feeling tired when getting up in the morning and a major decrease in libido.

In conclusion, I wonder if all of this is due to the clonazepam's side-effects, the depression or a combination of both. For the past 5 days I've been experimenting with the dosage (not exceeding the prescribed amount) and medication schedule. I now wait about 2 hours after breakfast and only take .500mg then wait 4-5 hours for the other
.500mg then have my usual 1mg before bedtime and these strange feelings have subsided quite significantly.

There's not usually a problem being on an SSRI and clonazepam at the same time. Many of my clients take both.

Thanks David, that was quite reassuring. I'll look up the various SSRI's so I'll have some kind of knowledge (compatibility, side-effects, etc.) before I see a physician or psychiatrist, had a few bad experiences in the past (diagnosis) and now do my "homework" before I commit myself to any kind of treatment...

Thank you all,
Gene

 

[Retired]

You may want to ask your doctor if the reason you are experiencing these adverse effects now that you are taking an anti-depressant along with clonazepam, that you may be experiencing some drug / drug interaction, which may require:

• switching to a different benzodiazepine (minor tranquilizer) or
• switching to a different anti depressant, or
• you may require a dosage change.

Most SSRI's do cause some side effects during the first few weeks, while your brain chemistry becomes acclimated to the new medication, but if after eight months you are experiencing drowsiness, light headedness and agitation, you would do well to report these to your doctor.

As for the decrease in libido, it may also be caused by the SSRI, but may also be a by-product of the illness of depression. But it too should be included in your discussion with the doctor. Usually an SSRI will cause difficulty in ejaculation, but it is well worth discussing with your doctor.

In your research, to prepare for your discussion with your doctor, consider that, based on the prescribing information for clonazepam, the manufacturer warns against potential drug / drug interactions at a site in the liver involving the cytochrome p-450 enzyme.

In the Psychlinks section discussing drug interactions, you will find extensive material on cytochrome p-450.

Some SSRI's compete for cytochrome p-450 while others do not, as do many other classes of medications.

That is to say, among many classes of medications, there are some which do require this metabolic pathway, while others do not, so the goal is to minimize the number of meds competing for the same liver enzyme.

The effect of two or more medications competing for this liver enzyme is that one or more of the medications may be poorly absorbed into the bloodstream, or too much may be absorbed resulting in adverse effects.

Your doctor along with your pharmacist should be able to provide you with options in the selection of the best combination of medications.

You can always use one of the medication interaction checkers that are listed in the Psychlinks medications interactions section.

Please also read Medicine-Net on clonazepam drug interactions

The Roche product monograph for clonazepam

 

[Gene53]

Hi Steve, thanks for the reply and the useful links.

You may want to ask your doctor if the reason you are experiencing these adverse effects now that you are taking an anti-depressant along with clonazepam, that you may be experiencing some drug / drug interaction, which may require:

* switching to a different benzodiazepine (minor tranquilizer) or
* switching to a different anti depressant, or
* you may require a dosage change.

As I mentioned in my first post "I've finally coaxed myself to see a psychologist and he suggested I also get a prescription for an antidepressant (plus psychotherapy) but I'm quite aware that clonazepam doesn't jive too well with other meds. Any advice on compatible meds would be appreciated.", so I haven't been prescribed an antidepressant yet because I only went to see the psychologist yesterday (Friday) so I'll have to wait till Monday to find an MD or psychiatrist. I've been living in Central America for the past 7 years and had to return to Canada 14 months ago to take care of a family emergency and will be going "back home" in 3 or 4 months. Needless to say, I don't have a physician here.

The weird thing is that those ill effects are probably a result of either the side-effects of the clonazepam (which is the only med I take and can provoke and/or aggravate depression after long-term use), a combination of the clonazepam and the depression or maybe the clonazepam just doesn't cut it any more and needs to be replaced with another med (or a combination of).

Once again, thanks for the links and info, much appreciated.

Cheers,
Gene

 

[David Baxter PhD]

As I said in the PM, you might do best by starting one of the dual action SSRI/SNRIs - Cymbalta or Effexor - and then trying to taper down or off the clonazepam slowly. Your psychologist might provide a bit of background with such a recommendation to a family physician.

 

[Gene53]

Hi David,

As I said in the PM, you might do best by starting one of the dual action SSRI/SNRIs - Cymbalta or Effexor - and then trying to taper down or off the clonazepam slowly.

Thanks for reply and I do feel I should taper down on the clonazepam till completely off it, I read on quite a few Mental Health forums/sites that prolonged use of this drug may cause most of what I've been feeling since the depression started and the side effects have increased along with the severity of my depression, which is now at it's worst (I really feel like I'm "losing it" and spend most of my days on an"anxiety roller coaster ride").

Another good reason to ween myself off it is that I have to take a SSRI/SNRI and the combo of any two meds do have interactions (from Drugs.com):

Clonazepam and Prozac, Effexor, Cymbalta, Celexa or escitalopram (Moderate Drug-Drug)
MONITOR: Central nervous system- and/or respiratory-depressant effects may be additively or synergistically increased in patients taking multiple drugs that cause these effects, especially in elderly or debilitated patients.

MANAGEMENT: During concomitant use of these drugs, patients should be monitored for potentially excessive or prolonged CNS and respiratory depression. Ambulatory patients should be counseled to avoid hazardous activities requiring complete mental alertness and motor coordination until they know how these agents affect them, and to notify their physician if they experience excessive or prolonged CNS effects that interfere with their normal activities.

So, if I'm going to be on a certain med (or a combo of), I'd sure as heck would like to have the least interactions/side-effects possible plus not making other ailments worse (PTSD, panic and other CNS disorders). If ever "big pharma" needs a "Side-Effects Poster Boy", I'd sure as heck be eligible, this is one of the reasons why I take meds only when absolutely necessary.

Your psychologist might provide a bit of background with such a recommendation to a family physician.

I'm seeing the psychologist again on Friday and we'll take a little time to discuss the above meds, darn thing is, with so few available doctors, I'm afraid it might take a little time before I do find one who will do follow ups in case I might need to modify the dosage and/or drug(s).

Cheers and thanks again,
Gene

 

[Halo]

Gene,

I know that I am sort of late coming into this thread and you have already received a lot of great information and suggestions but I just wanted to say that I am on an SSRI and Clonazepam together and have been now for almost 2 years and have had no interactions between the two. While I am now on a milder dose of Clonazepam, at one point I was on a stronger dose and even then I didn't have any difficulties. I know that it is scary to be adding medication with the potential of side-effects and all but I just basically wanted to let you know that it is possible to take both an SSRI or SNRI and Clonazepam together.

Anyway, I do think the best thing to do is to talk to your psychologist and then to your family doctor/psychiatrist and work out the best plan of action for you.

Good luck :goodluck:

 

[Gene53]

Hi Halo,

I am on an SSRI and Clonazepam together and have been now for almost 2 years and have had no interactions between the two

Thanks, that's quite comforting to know. Mind you, the clonazepam isn't doing what it's supposed to anymore, as I mentioned in one of my posts, I'm on an "anxiety roller coaster ride", as if the clonazepam has turned into a placebo.

then to your family doctor/psychiatrist and work out the best plan of action for you

That'll be the hardest part, finding a doctor and/or a psychiatrist..

Thanks,
Gene

 

[Halo]

That'll be the hardest part, finding a doctor and/or a psychiatrist..

I know that it will probably be difficult giving what the waiting lists can be for a family doctor and psychiatrist however hopefully your psychologist will have some ideas or solutions which may help.

Good luck :goodluck: and let us know how it goes.

 

[Retired]

There should be no concern about being prescribed an antidepressant medication along with a minor tranquilizer (benzodiazepine) since this a common treatment strategy.

The only consideration should be the correct choice of the combination, and most physicians should be aware of the potential for metabolic interaction between compounds. If there is an oversight, the pharmacist will usually pick these up, as long as all prescriptions are purchased at the same pharmacy (chain).

as if the clonazepam has turned into a placebo

Perhaps not. Your dosage may need to be adjusted, to regain the effectiveness you previously experienced. Another explanation might be that you are taking another prescription or even a non prescription medication that may be interfering with the clonazepam.

A number of non prescription meds such as cold and cough remedies or digestive disorder remedies (eg. Tagamet) or even pain relievers could be interfering with the clonazepam.

Gene, you may want to make a list of everything you are taking and have a conversation with your pharmacist. Be sure to speak to a pharmacist and not a pharmacy technician. You may get some insight into what's going on.

 

[Gene53]

I know that it will probably be difficult giving what the waiting lists can be for a family doctor and psychiatrist however hopefully your psychologist will have some ideas or solutions which may help.

Gee, this doctor situation is awful, the list of available doctors posted on the College of Physicians websites (both Ontario and Quebec) are outdated. So far, I must have called 15 places and got a "nay"...

Good luck :goodluck: and let us know how it goes.

Thanks and will do.

Such a lousy health care system, I'll be ecstatic to return to Central America in a few months, where everything is so much easier... :wave4:

Cheers,
Gene

---

Hi Steve, how are you?

There should be no concern about being prescribed an antidepressant medication along with a minor tranquilizer (benzodiazepine) since this a common treatment strategy.

I'm now convinced that it's the way to go, along with psychotherapy (and a heck of a good diagnosis).

The only consideration should be the correct choice of the combination, and most physicians should be aware of the potential for metabolic interaction between compounds. If there is an oversight, the pharmacist will usually pick these up, as long as all prescriptions are purchased at the same pharmacy (chain).

Makes sense but finding an MD is quite challenging whereas pharmacists are readily available, sure wish they could prescribe... On second thought, maybe I'd have better luck seeing my cat's veterenarian. LOL!

"as if the clonazepam has turned into a placebo"
Perhaps not. Your dosage may need to be adjusted, to regain the effectiveness you previously experienced. Another explanation might be that you are taking another prescription or even a non prescription medication that may be interfering with the clonazepam.

You may be right about the clonazepam, maybe a simple adjustment in dosage (along with an SSRI/SNRI) just might do the trick.

A number of non prescription meds such as cold and cough remedies or digestive disorder remedies (eg. Tagamet) or even pain relievers could be interfering with the clonazepam.

As I mentioned in one of my above posts, I'm not the type who likes to take meds. The only other "natural" med I'm now using is DGL ([SIZE=-1]Deglycyrrhizinated Licorice, wanted to post a link but I don't have the right to yet) [/SIZE]which I'm taking for my peptic ulcer and GERD (which the depression and anxiety has "revived" after many years of "inactivity"). I used to use Nexium but dropped it after 3 weeks usage, took care of the heartburn and GERD but left me feeling nauseous, bloated and constipated.

Gene, you may want to make a list of everything you are taking and have a conversation with your pharmacist. Be sure to speak to a pharmacist and not a pharmacy technician. You may get some insight into what's going on.

Done and I do talk to one pharmacist in particular, he's quite "savvy" and has always pointed me in the right direction. Also, I keep a very detailed journal on my computer and it's only a matter of printing it when needed.

Cheers,
Gene

 

[Retired]

Gene,

Please review the following article:

Licorice (Glycyrrhiza glabra L.) and DGL (deglycyrrhizinated licorice)-MedicinePlus-NIH

The article describes DGL and licorice from a scientific perspective provided by a reliable source (The National Institutes of Health (NIH) where licorice / drug interactions are described.

You may want to print that article and discuss it with your doctor and or pharmacist, because my reading of the interactions suggests that perhaps there may be a liver metablism issue causing the onset of the adverse reactions you are experiencing.

Quoted from the article:

In general, prescription drugs should be taken one hour before licorice or two hours after licorice because licorice may increase the absorption of many drugs. Increased absorption may increase the activities and side effects of some drugs (for example, nitrofurantoin). Phosphate salts have been shown to increase licorice absorption. Liver metabolism of certain drugs may be affected by licorice but further study is needed before a conclusion can be drawn

 

[Gene53]

Hi Steve and thanks for the concern.

In general, prescription drugs should be taken one hour before licorice or two hours after licorice because licorice may increase the absorption of many drugs. Increased absorption may increase the activities and side effects of some drugs (for example, nitrofurantoin). Phosphate salts have been shown to increase licorice absorption. Liver metabolism of certain drugs may be affected by licorice but further study is needed before a conclusion can be drawn

I was already aware of that warning and do follow the 1 and 2 hour recommendation but you may be right, I'll ask my pharmacist and I'll also email Dr. Michael Murray and also Dr. Andrew Weil (well known Natural Medicine MD's and ND's) and see what they have to say about the clonazepam/DGL combo.

I'll keep you updated on this matter. Darn thing is, if it does interfere, I'll have to hunt for another med for the gut problems that won't interact with the clonazepam and there's no way I'm going back to PPI's. DGL is doing a fantastic job, even better than the Nexium which I used to take.

Cheers,
Gene

---

Gee, wonderful, Got this automated reply from Dr. Murray's site:

Thank you for contacting me. Unfortunately, due to the enormous number of e-mails like yours that I was receiving I am unable to personally answer your question. Blah blah blah...

I'm sure he gets flooded with hundreds of questions per day but wouldn't it be courteous to simply remove "Ask Dr. Murray" from the main menu? Sure would prevent people from wasting time writing and getting nowhere.

:hissyfit:

Gene

 

[Retired]

I was unable, in the time I researched DGL to gain an understanding of the mechanism of the interaction described in the article.

That being said, when interactions take place in the liver, one of the most common mechanisms involves the cytochrome p-450 liver enzyme, where the compounds compete.

If there is a sound reason, where the benefits outweight the disadvantages or risks, to continue using DGL, and if the site of interaction is the one I suspect...and if your medical consultants link the interaction to the emergence of adverse reactions you have experienced, then perhaps a change from clonazepam to another minor tranquilizer (benzodiazepine) might be an option.

Your doctor would select a benzodiazepine appropriate to the diagnosis and select one with properties more compatible with the DGL.

There are benzodiazepines which are metabolized differently, some which do not require cytochrome p-450 stage of metabolism, which makes them options to consider when another compound is being taken that does require this stage of metabolism.

Hence no interaction.

There are a number of issues to be investigated by a competent medical specialist, who has a good understanding of pharmacokinetics and who can prescribe the right combination of medications to treat your diagnoses.

I have speculated based on the information you have provided. I would strongly suggest printing the resources I have referred to, and bringing them to your medical doctor to see if any of these options might apply to your situation.

 

[Gene53]

Hi Steve,

I was unable, in the time I researched DGL to gain an understanding of the mechanism of the interaction described in the article.

So have I, for the past 3 weeks or so, I must have read just about everything I could find on DGL but the info is so vague that you're left with more questions than answers.

That being said, when interactions take place in the liver, one of the most common mechanisms involves the cytochrome p-450 liver enzyme, where the compounds compete.

Thanks for the heads up on p-450, ever since you mentioned it in a previous post, I've been reading up a lot on it.

If there is a sound reason, where the benefits outweight the disadvantages or risks, to continue using DGL, and if the site of interaction is the one I suspect...and if your medical consultants link the interaction to the emergence of adverse reactions you have experienced, then perhaps a change from clonazepam to another minor tranquilizer (benzodiazepine) might be an option.

This is a "damned if you do and damned if you don't" type of situation and I think a little experimentation is mandatory, I think I'll skip the DGL for 36 to 48 hours and see if I metabolize the clonazepam better, darn thing is, my gut might flare up again (heartburn and GERD). As far as changing benzodapines go, I'm all for it but according to what I've read and heard, you just can't go "cold turkey" on the clonazepam, it has to be done over an extended period of time, especially that I've been on this med for over 12 years.

Here's an excerpt of what you'll find all over the net:
"Avoid Abrupt Cessation, taper dose gradually to D/C if at risk for physical dependence (abrupt cessation of benzodiazepines or barbiturates may cause a withdrawal syndrome including irritability, anxiety, agitation, dysphoria, confusion, memory deficits, hallucinations, sensory disturbances, paresthesias, psychosis, seizures, insomnia, tremors, muscle twitching, muscle cramps, abdominal cramps, GI disturbances, tachycardia, diaphoresis)"

There are benzodiazepines which are metabolized differently, some which do not require cytochrome p-450 stage of metabolism, which makes them options to consider when another compound is being taken that does require this stage of metabolism.

Hence no interaction.

I've already sent the DGL manufacturer (Natural Factors) an email asking if any DGL/clonazepam interactions have ever been reported and here's an excerpt from their reply:
"Our Research and Information Services department have advised that there are no known drug interactions between this product and the drugs you have listed"

So, I assume that the next question I should ask them would be "does DGL or any of it's components require a cytochrome p-450 stage of metabolism?". I kind of wonder what kind of answer I'll get and hopefully there are microbiologists in their R&D dept. who can answer that question.

There are a number of issues to be investigated by a competent medical specialist, who has a good understanding of pharmacokinetics and who can prescribe the right combination of medications to treat your diagnoses.

That's what my problem is, can't even find a run-of the-mill physician, we must have called over 30 clinics since yesterday and the answer is carbon copy, "sorry, we don't accept new patients at this time but if you wish, you may leave us your name and phone number and we'll add you to our waiting list"...

What really "tees me off" is that if my business here in Canada was done and over with, I could hop a plane back to Costa Rica tonight and see any doctor or specialist by tomorrow afternoon or the next day at the latest... Not bad for a "Third World Country" or a "Banana Republic", they have better healthcare than we do.

I have speculated based on the information you have provided. I would strongly suggest printing the resources I have referred to, and bringing them to your medical doctor to see if any of these options might apply to your situation.

Thanks for the care and research Steve, but as I said, "no doctor, no care". As David mentioned in a PM "SSRIs are not difficult to manage medically so family physicians are usually comfortable prescribing them. If not, your only choice would be a walk-in clinic but they would be less likely to prescribe such medication to someone they don't know." and the darn this is, the only option I have left is a walk-in clinic...

Cheers,
Gene

 

[Retired]

Gene,

Sorry to hear about the difficulty you're having to find a doctor. It's a frustration we experience in many parts of Canada.

Avoid Abrupt Cessation, taper dose gradually .......

As a general rule, abrupt discontinuation of any medication should be avoided. However everything in medicine, has to have a rationale, and this rule depends largely on either the mechanism of action or the biologic half life of the medication in question.

In the case of benzodiazepines, the rationale dealing with cessation rate depends on half life, however if a person has been taking the medication for a long time (years) or at a relatively high dose, tapering would similarly be advisable to help avoid symptoms of withdrawl.

Clonazepam ranks in the short to moderate half life grouping of minor tranquilizers, and one would be wise to follow a tapering schedule if cessation were planned.

However if your doctor is switching to another benzodiazepine, there would be no need to cease the first, as a "wash out" is not required when switching from one benzodiazepine to another.

Here is an article which describes the implications of the half life of benzodiazepines and provides a good list of the half lifes of many benzodiazepines.

No medication should be stopped without consulting a physician, and a schedule for tapering the dose should be discussed with the physician to help avoid symptoms of withdrawl.