Advice for an antidepressant needed

[Gene53]

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.

Wonderful, isn't it? The way I hear it in my region is that a lot of MD's have moved their practices from Quebec to Ontario (OHIP pays more than RAMQ does) and Ontario doctors move to the States, where there's no socialized healthcare and make even more money. It is unfortunate that medicine is now a business instead of a vocation.

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.

I did follow the below link and found it to be quite interesting but mind you, I've been taking this med for more than 12 years at 2MG's/day.

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.

Interesting but the big challenge now is to find a doctor who's quite savvy in that area but as I said, so far I've only encountered "nays".

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.

As I mentioned above, quite informative and I saved it so I may print it, if ever I do find a doctor.

What really caught my attention was:
"Nevertheless, people on potent benzodiazepines such as alprazolam, lorazepam (Ativan) or clonazepam (Klonopin) tend to be using relatively large doses. This difference in potency is important when switching from one benzodiazepine to another"
"Clearly, with repeated daily dosing accumulation occurs and high concentrations can build up in the body (mainly in fatty tissues). There is a considerable variation between individuals in the rate at which they metabolise 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.

What is a Physician? Where do you find one? Are they on the Endangered Species list? Think I should try finding one in a museum? Would it be easier to get an appointment with the German Chancellor? (sorry, rambling...)

BTW, Steve, I sent another message to Natural Factors asking if any of the DGL ingredients require the cytochrome p-450 stage (liver enzyme) of metabolism. I'll probably have an answer tomorrow. I also skipped the DGL at dinner and as I said in an above post, won't be taking it for a day or two only to see if there's any change.

Today was awful, I woke up restless and could feel that I had had an anxiety attack during the night. About an hour after getting out of bed, I went on another anxiety roller coaster ride and my head was spinning as if I were experiencing vertigo so I ended-up pacing the living/dining area for about 4 1/2 hours (which is what I always do when anxious, have to move) and now feel like I participated in a marathon (and came in last).

Also, I'd like to mention that the other DGL ingredients besides the licorice are dextrose, cellulose, maltodextrine, guar gum and magnesium stearate. Wonder if any of those (or the licorice) need the p-450 to metabolize...

Thanks again,
Gene

 

[Retired]

These assertions from the article caught my attention as well, and IMO weaken an otherwise solid discussion

"Nevertheless, people on potent benzodiazepines such as alprazolam, lorazepam (Ativan) or clonazepam (Klonopin) tend to be using relatively large doses.

I'm puzzled by this statement, by someone who identifieshimself as a pharmacologist. Once a compound is found to be safe and effective, the next step is to determine the lowest effective dose. Depemding on the structure and properties of any given molecule, it may take more or less quantity to achieve a similar clinical result.

Therefore 1 mg. lorazepam would give the approximate clinical effect as 10 mg of diazepam, and 30 mg oxazepam.

A common analogy used to differentiate effective dose and potency is a like comparing an ounce of whiskey to a jug of beer. The smaller quantity is more potent, so you use less a similar effect.

The statement made "tend to be using relatively large doses" completely eludes me fails to make a point.

This difference in potency is important when switching from one benzodiazepine to another"

Again, I don't see the clinical point to this statement, as the prescribing physisican will take dosage into consideration. More important is the metabolic half life, active metabolites and metabolic pathways in making changes from one benzo to another.

"Clearly, with repeated daily dosing accumulation occurs and high concentrations can build up in the body (mainly in fatty tissues).

Whether clinicall significant is not clear and I would want to see literature supportig that claim. More insidious is the accumulation in the bloodstream of long acting compounds such as diazepam and chlordiazepoxide, which have cause serious deterioration in quality of life due to technical overdosing, especially in older patients with compromised liver and kidney function.

There is a considerable variation between individuals in the rate at which they metabolise benzodiazepines."

Now that's true! Depends on many factors such as body weight, overall health, liver and kidney function, and especially age. Anyone over 65 and especially over 70 must be prescribed a fraction of the usual adult daily dose; and must be monitored more closely.

The opinions I have expressed are based on my understanding of the literature as it pertains to these medications. I am not a health care professional. Please use this information as a resource to discuss your options with a qualified and competent health professional.

 

[Gene53]

Steve, I reread the article once again and even though I'm a "newbie" at this, I did find a few contradictions (and gray areas) myself. Talk about confusion...

The opinions I have expressed are based on my understanding of the literature as it pertains to these medications. I am not a health care professional. Please use this information as a resource to discuss your options with a qualified and competent health professional.

I sure wish you were, perhaps you'd be taking in new patients... :doctor:

Thanks and I'll keep you updated on the DGL (or lack of) thing.

Cheers and thanks again,
Gene

Thanks and I'll keep you updated on the DGL (or lack of) thing.

So far, so good. I stopped taking the DGL yesterday morning and today my anxiety level was way down compared to yesterday and my ulcer hasn't acted up yet. It might be a little too soon to come to a conclusion, let's wait another day or two...

Cheers,
Gene

p.s. called another 20 or so doctors today and still no luck...

 

[Halo]

Gene,

Are you looking in Quebec or Ottawa or both? I ask because although I have no magical solution, I may be able to help in your search and just wanted to know which province you were looking at.

 

[Gene53]

Gene,

Are you looking in Quebec or Ottawa or both? I ask because although I have no magical solution, I may be able to help in your search and just wanted to know which province you were looking at.

Hi Halo,

I'm looking in both the Ottawa-Carleton and Outaouais regions, being that I haven't renewed my health insurance card (my permanent residence is in Central America) so I pay as I go along just like a tourist would (which I now consider myself to be, LOL!).

The only reason I had to come back here over a year ago was for a family emergency and I expect that everything I need to do here will be done and over with in 4 to 5 months then will be heading "back home".

Thank you,
Gene

 

[Gene53]

Sorry for reviving this thread but I was wondering about the following:

Being that I have an appointment with the psychiatrist on the 22nd. I wonder if it would be appropriate for me to ask for a "mild" antidepressant, only to take the edge off. Personally, I don't want to be over-sedated to the point that it puts too much of a damper on my emotions for I strongly believe that "letting it all out" and "dealing with my demons" is the key to my recovery, as it has in the past.

I'm quite aware that he's the expert but I would like to put my 2 cents worth in this matter.

Cheers,
Gene

 

[Into The Light]

i don't think you need to worry about anti-depressants "suppressing" your real emotions. really what they do is help with the worst of the feelings depression brings on but in no way do they erase your issues (it sounds like you may think they do).

depression causes strong negative emotions that are out of proportion. the anti-depressants reduce that intensity. but they aren't happy pills, they're a tool to help you be able to deal with your issues.

 

[Retired]

Gene,

Any discussion can be revived at any time. You are always welcome to do so.

My view of what a relationship between a patient and their physician should be, is that of a partnership.

There should be open dialigue regarding the patient's concerns and the treatment options.

Most of today's physicians have adopted that style, although there may be some hold outs to the paternalistic and authoritatrian style of the fifties, where the physician was never questioned, challenged or provided with input.

Therefore you could most certainly ask your doctor if s/he would think it appropriate to prescribe an antidepressant medication to help relieve the mood changes and anxiety you might be feeling.

Continue with your research as you have been doing to learn about treatment options, and if you have any questions about what you find, let us know.

 

[Gene53]

Thank you friends, makes things a bit more reassuring.

 

[Gene53]

Hi folks,

I finally went to see the PDoc this morning as I had heard, he was an older gentleman and really looked old school but I figured "what the hey, nothing to lose". He asked me a truckload of questions about my family history, the effects that clonazepam had on me, my depression, sleeping patterns, PTSD, OCD and phobias. Anyways, the interview (or third degree, LOL!) lasted for 45 minutes then he prescribed Celexa (once a day, at bedtime) and Trazodone (at bedtime, but I think I might hold off on that one till I'm sure the Celexa is not interfering with the Clonazepam). According to drug interactions sites, there's a minor drug-drug interaction between Celexa and Clonazepam whereas Celexa and Trazodone have a MAJOR drug-drug interaction.

He also adjusted my Clonazepam by dividing the 2mg/day into 4 dosages of .5mg every 4 hours or so, the way I was taking it wasn't working well anymore (1mg/twice daily) for it would peak and then die off (half-life is 4 hours) so this way, it'll have a continued effect and I shouldn't feel it's ups and downs as badly.

Cheers,
Gene

 

[David Baxter PhD]

he prescribed Celexa (once a day, at bedtime) and Trazodone (at bedtime, but I think I might hold off on that one till I'm sure the Celexa is not interfering with the Clonazepam). According to drug interactions sites, there's a minor drug-drug interaction between Celexa and Clonazepam whereas Celexa and Trazodone have a MAJOR drug-drug interaction.

I would strongly advise you to follow the doctor's advice.

1. There is unlikely to be a problematic interaction between Celexa and clonazepam.

2. There is unlikely to be a problematic interaction between Celexa and trazodone at normal doses.

3. The trazodone is generally prescribed to help with sleep.

 

[Halo]

I agree with David. Gene, I really would follow your doctor's advice. Although he may be old school, he still has knowledge and expertise in this area that the average person such as you and I don't and therefore knows what he is talking about. I really think that the medications are going to be helpful for you but only if they are taken correctly.

 

[Gene53]

All right, David and Halo, you've convinced me, please disregard my previous statement.

LOL! I've had so many bad drug interactions for so long that I'm almost paranoid in trying something new.

BTW David, the Celexa is only once daily and at bedtime also (if I read the prescription right, Celexa, 20mg, 1H and trazodone, 50mg, 1H) so I assume this is low dosage.

Thanks,
Gene

 

[David Baxter PhD]

Yes, the Celexa dose is an average starter dose and the trazodone at 50 mg is a low dose.

The reason for the warning, incidentally, is because they are both antidepressants - however, trazodone is not commonly prescribed for depression because it makes people sleepy - hence, its use for insomnia. If one were taking these medications together at high doses, there might be a problem to worry about but your doctor will already know this.

 

[Gene53]

Yes, the Celexa dose is an average starter dose and the trazodone at 50 mg is a low dose.

The reason for the warning, incidentally, is because they are both antidepressants - however, trazodone is not commonly prescribed for depression because it makes people sleepy - hence, its use for insomnia. If one were taking these medications together at high doses, there might be a problem to worry about but your doctor will already know this.

Thanks David, great explanation and I now feel reassured.

What freaked me out is the following: MONITOR CLOSELY: Concomitant use of agents with serotonergic activity such as serotonin reuptake inhibitors, monoamine oxidase inhibitors, tricyclic antidepressants, 5-HT1 receptor agonists, ergot alkaloids, lithium, St. John's wort, phenylpiperidine opioids, dextromethorphan, and 5-hydroxytryptophan may potentiate the risk of serotonin syndrome, which is a rare but serious and potentially fatal condition thought to result from hyperstimulation of brainstem 5-HT1A receptors.

Cheers,
Gene

 

[Halo]

Gene,

I am glad that you are going to follow your doctors advice and take the medication as prescribed. As I said, I really do think that it is going to help.

Let us know how it goes.

Take care

 

[Retired]

Gene,

This is one of those situations where, along with the good research you are doing to understand the actions and kinetics of the medications you have been prescribed, you need to rely on the clinical judgment of your physician.

That is not to say you should not discuss your findings with the doctor, because by doing what you are doing, you are working as a partner in your healthcare with your physician.

That being said, physicians gain clinical experience using certain combinations of medications that generally work well for their patients, and they gain a familiarity with these therapeutic strategies.

Older physicians generally stay in touch with newer treatment strategies through regular information exchanges in hospital (rounds) as well as specialized conferences, journal articles and other resources.

For your interest I will point you to the official Canadian product monograph on file with Health Canada. While monographs may vary slightly from one Country to the next, as you are in Canada, being treated by a Canadian physician, it would help to be on the same page.

Trazodon (Desyrel tabs) CDN monograph

Celexa (cetalopram) CDN monograph

On both these pages, click on Product Monograph to view the PDF file

What freaked me out is the following...................

As David and the others have reassured you, following your doctor's prescribing regimen is unlikely to cause difficulties. The concern here is primarily Serotonin syndrome which should not be a concern given the combination of compounds you listed.

However, more likely to be of concern is the potential for drug / drug interaction with trazodone, since this compound utilizes the cytochrome P-450 liver enzyme system.

Going back to the very beginning of this discusssion, I pointed out that clonazepam utilizes cytochrome P-450 for its metabolism as well. This competition for the enzyme may result in higher than expected blood levels of trazodone, causing unexpected adverse effects.

Your doctor is probably aware of this intereaction potential and has likely modified the dosage accordingly, but this is a subject worthy of discussion with the doctor as well as the pharmacist.

In addition there are a number of OTC medications that use this same metabolic pathway, so you need to review everything you use with your pharmacist.

Typical examples are cimetidine ( for digestive disorders) cough and cold preparations containing dextromethorphan and anti histamines, some anti biotics, and for women, oral contraceptives.

In summary,

• I would say follow your doctor's recommendations.
• Discuss your findings about drug interactions for your doctor's comments
• Review all meds, Rx'ed, OTC, herbs etc with your pharmacis for any interaction potential.
• Give the medications a chance to reset your neurochemistry, and look forward to improved days ahead.

 

[Into The Light]

it sounds like he really looked at your personal history before he gave you those prescriptions and that he put a lot of thought into it. i am glad to hear it, it sounds like he's on the ball, which is reassuring. keep us posted on how you are feeling. i hope there will be improvements very soon for you

 

[Gene53]

Older physicians generally stay in touch with newer treatment strategies through regular information exchanges in hospital (rounds) as well as specialized conferences, journal articles and other resources.

The PDoc has quite a few years under his belt working mostly in institutions and hospitals so I guess I do have to have faith in someone.

Trazodon (Desyrel tabs) CDN monograph

Celexa (cetalopram) CDN monograph

On both these pages, click on Product Monograph to view the PDF file

Thanks for the links.

However, more likely to be of concern is the potential for drug / drug interaction with trazodone, since this compound utilizes the cytochrome P-450 liver enzyme system.

Going back to the very beginning of this discusssion, I pointed out that clonazepam utilizes cytochrome P-450 for its metabolism as well. This competition for the enzyme may result in higher than expected blood levels of trazodone, causing unexpected adverse effects.

Your doctor is probably aware of this intereaction potential and has likely modified the dosage accordingly, but this is a subject worthy of discussion with the doctor as well as the pharmacist.

I did mention the P-450 enzyme (he never expected that, caught him off-guard, LOL!) but as I said, he adjusted the clonazepam dosage by splitting it in 4 smaller dosages instead of 2 larger ones. I guess the only way to find out is to try and see what happens. The last thing that bugs me about Celexa/trazodone/clonazepam cocktail is "MONITOR: Central nervous system- and/or respiratory-depressant effects may be additively or synergistically increased in patients taking multiple drugs that cause these effects" and the darn thing is, I do have the occasional bout with asthma (seasonal allergies) and am prone to bronchitis which I did mention but he did assure me that the dosages weren't high enough to cause repiratory-depressant effects.

I would say follow your doctor's recommendations.

Makes sense, I really want to beat this beast before heading back south.

Discuss your findings about drug interactions for your doctor's comments

I do keep a journal and I made sure I could call him in case of adverse side effects.

Review all meds, Rx'ed, OTC, herbs etc with your pharmacis for any interaction potential.

I will double check with the pharmacist but at least, I don't take any OTC medicines (not even tylenol unless I really have to).

Give the medications a chance to reset your neurochemistry, and look forward to improved days ahead.

Don't you wish we had reset (or reboot) buttons? LOL! Seems that it may take a few weeks for the medications to do it's trick. I do have another appointment with him on Sept. 2 for monitoring purposes.

Thanks Steve,
Gene

Thanks Halo and Into the Light, I'll keep you posted.

BTW, are any of you on that clonazepam/trazodone/celexa cocktail? If so, I'd appreciate some feedback.

Cheers,
Gene

 

[Retired]

not even tylenol unless I really have to

You can safely take Tylenol (acetomenophen) as it does not compete for cytochrome P-450.

I did mention the P-450 enzyme

Good..remember when referring to this particular mode of liver metabolism, refer to it by it's complete name: cytochrome P-450

There are a number of very thorough articles on Psychlinks describing this mechanism in our Interactions section.

The last thing that bugs me about Celexa/trazodone/clonazepam cocktail is "MONITOR: Central nervous system- and/or respiratory-depressant effects may be additively or synergistically increased in patients taking multiple drugs that cause these effects" and the darn thing is, I do have the occasional bout with asthma (seasonal allergies) and am prone to bronchitis which I did mention but he did assure me that the dosages weren't high enough to cause repiratory-depressant effects.

On this point, you can rely on your doctor's clinical judgement. All medications that suprress the Central Nervous system, and these cross many lines of classifications such as psychotropic meds, pain relievers (analgesics) and many others contain this very warning in their monographs (Regulatory Agency requirement) and is dose related.

Your doctor is well aware of the additive effect of these medications and is protecting your health interests.

You could always ask your pharmacist for a second opinion,for your personal satisfaction, but in an earlier post, Dr. Baxter shared his reasurance based on his clinical experience as well.

In time you should be feeling better. However monitor your body responses, and be prepared to report any changes, good or bad with your doctor on your next visit.