Vortioxetine 10 mg

[MyNameIsTerry]

There seems to be a great deal of discontent for the NHS in this forum which is quite disheartening as I am currently training to be a Doctor myself, although I am intending to specialise in Neurology not Psychiatry. There also seems to be quite a few misconceptions related to how the NHS prescribes medications and what it prescribes. One of which is that Pregabalin isn't given to patients as the brand of if by Pfizer is expensive. It's true that Lyrica is expensive somewhere in the region of £95 a month, however, there are plenty of generic versions available which can easily be found on the EMC, which will be about the same price as Vortioxetine. The more common reason that Pregabalin is unlikely to be prescribed for anxiety is because Pregabalin works by binding to what are called voltage dependent Calcium channels which when are opened on nerve cells cause positively charged Calcium ions to go into the cell which leads to neurotransmitters such as Noradrenaline and Dopamine to leave the cell. This means that Pregabalin simply stops nerves from sending these neurotransmitters out meaning that its anxiolytic effect is simply by making the patient feel drunk, drunkenness is even one of the most commonly reported side effects as is euphoria and ataxia. This why many Doctors are reluctant to prescribe it as you are essentially getting the patient drunk to treat their anxiety, not only this but prolonged use of such drugs can lead to issue with the pacemaker of the heart called the sinoatrial node.

As far as the whole Mirtazapine is prescribed alot because it is "dirt cheap" this simply isn't true it is used because it acts as a presynaptic Alpha2-Adrenoceptor antagonist meaning that it will increase nerve cell output of Noradrenaline and Serotonin and many patients don't want to get sexual dysfunction and Mirtazapine doesn't cause this, however it isn't licensed to be used in Anxiety disorders in the United Kingdom. It is also a very potent Histamine H1 receptor antagonist which means that it can sometimes be used in anxiety for its sedative effects.

Pregabalin prescribing is marred by more factors than you state, something we are used to seeing on the Preg board. And let's not forget Buckinghamshire in blacklisting it for all uses.

Remember that generic Preg is newer so older posts aren't based on it. And there was the recent legal challenges that pushed the NHS to prescribe branded until the court case was over.

NICE recommend use of Sert on the basis of cost effectiveness rather than patient need. Are we expected to believe the NHS don't make similiar decisions all over? (See Buckinghamshire & Preg again which was a cost cutting exercise)

Mirt may not be licensed specifically but if NHS trusts issue guidance to use it in anxiety, GP's will. There are SSRI's that are only licenced outside of anxiety disorders yet are used mainstream as a first line treatment for them, and are recommended in trust prescribing guidelines.

As far as negativity goes, have you not been trained to understand bias? We have thousands of threads about bad experiences with alcohol but don't you think that's because the only people who raise an issue do so because they have experienced one? Surely you shouldn't expect to see thousands of pointless "yep, I drank fine" threads?

[lliiaamm0099]

Pregabalin prescribing is marred by more factors than you state, something we are used to seeing on the Preg board. And let's not forget Buckinghamshire in blacklisting it for all uses.

Remember that generic Preg is newer so older posts aren't based on it. And there was the recent legal challenges that pushed the NHS to prescribe branded until the court case was over.

NICE recommend use of Sert on the basis of cost effectiveness rather than patient need. Are we expected to believe the NHS don't make similiar decisions all over? (See Buckinghamshire & Preg again which was a cost cutting exercise)

Mirt may not be licensed specifically but if NHS trusts issue guidance to use it in anxiety, GP's will. There are SSRI's that are only licenced outside of anxiety disorders yet are used mainstream as a first line treatment for them, and are recommended in trust prescribing guidelines.

As far as negativity goes, have you not been trained to understand bias? We have thousands of threads about bad experiences with alcohol but don't you think that's because the only people who raise an issue do so because they have experienced one? Surely you shouldn't expect to see thousands of pointless "yep, I drank fine" threads?

GP's should really know better to prescribe SSRI's or any drug that is not licensed for anxiety for that matter such as Mirtazapine. Pharmaceutical companies do clinical trials and if the drug isn't licensed for an anxiety disorder then it has not been found effective for treating it. Fluoxetine is a perfect example many GP's will prescribe this for anxiety, which they shouldn't, it will often make anxiety worse as it has a tendency to increase Noradrenaline and Dopamine in the brain this can be very activating and even make insomnia worse. Pregabalin being blacklisted by Buckinghamshire may be due to cost but people also need to remember that Pregabalin acts as a central nervous system depressant which means it will have an abuse potential especially if a person takes a very high dose in a short space of time and euphoria is a common side effect there is now even talk of making it a class C because of this side effect. I remember a person on another anxiety board who would freely admit to taking higher doses than they were supposed to because they liked its effect

As far as the negativity is concerned about the NHS what I mean is there many people who are more than happy to complain because they are after some drug that simply doesn't exist. There is no drug which 100% effective for anxiety which has no side effects. Different people will react better to certain drugs and if people think this is the NHS's fault then feel free to join BUPA and be told the exact same thing about the exact same drugs. BUPA offers SSRI's, SNRI's, Tricyclics and MAOIs for anxiety disorders. Just like the NHS but nobody can say BUPA offers these because they are trying to save money.

If anybody has serious anxiety that hasn't responded to 3 drugs I would highly recommend Phenelzine which is an old Monoamine Oxidase Inhibitor (MAOI) this increases Serotonin, Noradrenaline, Dopamine and GABA which have all been associated with anxiety. GABA is the most likely cause for its anxiolytic effects as this drug inhibits its breakdown.It might be an old drug but many people still swear that it is the most effective antidepressant/anxiolytic drug ever, although it does have dangerous food interactions which rarely have been fatal. If a doctor/psychiatrist doesn't prescribe this a person could ask for a drug called Sodium Valproate this also inhibits the breakdown of GABA and it is very calming so much so that it is effective in treating the manic phase of bipolar disorder. Remember each doctor is an independent prescriber so if they feel a drug may harm you they are unlikely to prescribe as they will get into trouble for it so you just need to convince them you will be fine on a drug.

[pulisa]

Is moclobemide prescribed anymore?

[lliiaamm0099]

Is moclobemide prescribed anymore?

Yeah Moclobemide is prescribed but it is usually by a psychiatrist although GP's can usually email a psychiatrist at your local hospital and they can approve it through that, they will see your medical notes and decide if it is right for you.
Although Moclobemide is a relatively weak MAOI as its effects are reversible as opposed to that of Phenelzine and Isocarboxazid

[panic_down_under]

GP's should really know better to prescribe SSRI's or any drug that is not licensed for anxiety for that matter such as Mirtazapine. Pharmaceutical companies do clinical trials and if the drug isn't licensed for an anxiety disorder then it has not been found effective for treating it.

The SSRIs are generally better anxiolytics than they are anti depressives. Pharmaceutical companies have traditionally concentrated on developing drugs for depression because it is considered to be the main market, so they haven't always bothered running trials for anxiety disorders. However, anxiety and depression are just differing points on the spectrum of symptoms produced by the same underlying biological deficits so what works for one will usually work for the other.

If anybody has serious anxiety that hasn't responded to 3 drugs I would highly recommend Phenelzine which is an old Monoamine Oxidase Inhibitor (MAOI)

...It might be an old drug but many people still swear that it is the most effective antidepressant/anxiolytic drug ever

I agree that the MAOIs are much underrated antidepressants, but imho, tranylcypromine (Parnate) is the better MAOI. Unlike phenelzine it isn't potentially liver toxic, has linear pharmacokinetics, isn't hypoglycemic, generally doesn't trigger weight gain, nor cause deficiency of some B group vitamins.

although it does have dangerous food interactions which rarely have been fatal.

Modern food processing techniques have considerably diminished the risk. The blood pressure spike can probably be almost completely eliminated by adding a noradrenaline/norepinephrine reuptake inhibitor such as nortriptyline (Pamelor) to block the tyramine pressor response.

These days the biggest problem with MAOIs is finding a psychiatrist who doesn't faint as the prospect of prescribing them. GPs are even less likely to consider them. Plus, I understand the few companies still making them have been ramping up prices in recent years too.

increases Serotonin, Noradrenaline, Dopamine and GABA which have all been associated with anxiety. GABA is the most likely cause for its anxiolytic effects as this drug inhibits its breakdown.

...could ask for a drug called Sodium Valproate this also inhibits the breakdown of GABA and it is very calming

No normally functioning brain lacks GABA. It is a by-product of the Krebs/citric acid cycle which fuels the brain and is so abundant that the blood-brain-barrier has billions of tiny pumps to remove the excess. [1] What we do lack is benzodiazepine binding sites, and the ones we do have are less sensitive. [2] Trying to overcome this deficit by increasing GABA levels is akin to trying to cure faulty spark plugs by overfilling the petrol/gas tank.

Sodium valproate works by inhibiting the entry of positively charged sodium ions into cells making it harder for them to raise voltages to the firing potential. Benzodiazepines accomplish the same thing by increasing the entry of negatively charged chlorine ions into cells.


References:

[1]
Kakee A, Takanaga H, Terasaki T, et al (2001)
Efflux of a suppressive neurotransmitter, GABA, across the blood-brain barrier.
J Neurochem. Oct;79(1):110-8 [["url=http://www.ncbi.nlm.nih.gov/pubmed/11595763"]Abstract[/url] | Full text PDF]

Terasaki T1, Hosoya K. (1999)
The blood-brain barrier efflux transporters as a detoxifying system for the brain.
Adv Drug Deliv Rev. 1999 Apr 5;36(2-3):195-209 [Abstract]

[2]
Hasler G, Nugent AC, Carlson PJ, et al. (2008)
Altered cerebral gamma-aminobutyric acid type A-benzodiazepine receptor binding in panic disorder determined by [11C]flumazenil positron emission tomography.
Arch Gen Psychiatry. Oct;65(10):1166-75 (Abstract)

Geuze E, van Berckel BN, Lammertsma AA, et al. (2007)
Reduced GABAA benzodiazepine receptor binding in veterans with post-traumatic stress disorder.
Mol Psychiatry. 2008 Jan;13(1):74-83 (Abstract)

Cameron OG, Huang GC, Nichols T, et al. (2007)
Reduced gamma-aminobutyric acid(A)-benzodiazepine binding sites in insular cortex of individuals with panic disorder.
Arch Gen Psychiatry. Jul;64(7):793-800. (Abstract)

Bremner JD, Innis RB, Southwick SM, et al. (2000)
"Decreased benzodiazepine receptor binding in prefrontal cortex in combat-related posttraumatic stress disorder."
Am J Psychiatry Jul; vol 157(7):1120-6 (Abstract)

Bremner JD, Innis RB, White T, et al (2000)
"SPECT [I-123]iomazenil measurement of the benzodiazepine receptor in panic disorder."
Biol Psychiatry Jan 15; vol 47(2):96-106 (Abstract)

Malizia AL. (1999)
"What do brain imaging studies tell us about anxiety disorders? "
J Psychopharmacol Dec; vol 13(4):372-8 (Abstract)

Morimoto K. 1999
Benzodiazepine receptor imaging in the brain: recent developments and clinical validity
Kaku Igaku. May;36(4):307-13. (Abstract)

Malizia AL, Cunningham VJ, Bell CJ, et al. (1998)
"Decreased brain GABA(A)-benzodiazepine receptor binding in panic disorder: preliminary results from a quantitative PET study."
Arch Gen Psychiatry Aug; vol 55(8):715-20 (Abstract)

Tokunaga M, Ida I, Higuchi T, Mikuni M. (1997)
"Alterations of benzodiazepine receptor binding potential in anxiety and somatoform disorders measured by 123I-iomazenil SPECT."
Radiat Med May-Jun; vol 15(3):163-9 (Abstract)

Uchiyama M, Sue H, Fukumitsu N, et al. (1997)
"Assessment of cerebral benzodiazepine receptor distribution in anxiety disorders by 123I-iomazenil-SPECT: comparison to cerebral perfusion scintigraphy by 123I-IMP."
Nippon Igaku Hoshasen Gakkai Zasshi Jan; vol 57(1):41-6 (Abstract)

---------- Post added at 12:43 ---------- Previous post was at 12:41 ----------

Is moclobemide prescribed anymore?

Yes, but this might be moot as it rarely works, ime.

[lliiaamm0099]

Sodium valproate works by inhibiting the entry of positively charged sodium ions into cells making it harder for them to raise voltages to the firing potential. Benzodiazepines accomplish the same thing by increasing the entry of negatively charged chlorine ions into cells.

Sodium Valproate is a GABA Transaminase inhibitor mainly though. It does have effects on Sodium channels but if this was its only mechanism I wouldn't be able to prescribe it to my patients who suffer from absence seizures as this form of epilepsy is usually exacerbated by drugs effecting sodium and calcium channels such as Carbamazepine and Pregabalin. This is why I can give them Valproate but if I gave them Pregabalin I could guarantee that they would have significantly more seizures and they would also be more severe.
In order for Benzodiazepines to work the brain has to have a high supply of GABA anyway as they work as positive allosteric modulators meaning they can only work in the presence of GABA to open up the channel to let in the chloride ions.

[MyNameIsTerry]

GP's should really know better to prescribe SSRI's or any drug that is not licensed for anxiety for that matter such as Mirtazapine. Pharmaceutical companies do clinical trials and if the drug isn't licensed for an anxiety disorder then it has not been found effective for treating it. Fluoxetine is a perfect example many GP's will prescribe this for anxiety, which they shouldn't, it will often make anxiety worse as it has a tendency to increase Noradrenaline and Dopamine in the brain this can be very activating and even make insomnia worse. Pregabalin being blacklisted by Buckinghamshire may be due to cost but people also need to remember that Pregabalin acts as a central nervous system depressant which means it will have an abuse potential especially if a person takes a very high dose in a short space of time and euphoria is a common side effect there is now even talk of making it a class C because of this side effect. I remember a person on another anxiety board who would freely admit to taking higher doses than they were supposed to because they liked its effect

As far as the negativity is concerned about the NHS what I mean is there many people who are more than happy to complain because they are after some drug that simply doesn't exist. There is no drug which 100% effective for anxiety which has no side effects. Different people will react better to certain drugs and if people think this is the NHS's fault then feel free to join BUPA and be told the exact same thing about the exact same drugs. BUPA offers SSRI's, SNRI's, Tricyclics and MAOIs for anxiety disorders. Just like the NHS but nobody can say BUPA offers these because they are trying to save money.

If anybody has serious anxiety that hasn't responded to 3 drugs I would highly recommend Phenelzine which is an old Monoamine Oxidase Inhibitor (MAOI) this increases Serotonin, Noradrenaline, Dopamine and GABA which have all been associated with anxiety. GABA is the most likely cause for its anxiolytic effects as this drug inhibits its breakdown.It might be an old drug but many people still swear that it is the most effective antidepressant/anxiolytic drug ever, although it does have dangerous food interactions which rarely have been fatal. If a doctor/psychiatrist doesn't prescribe this a person could ask for a drug called Sodium Valproate this also inhibits the breakdown of GABA and it is very calming so much so that it is effective in treating the manic phase of bipolar disorder. Remember each doctor is an independent prescriber so if they feel a drug may harm you they are unlikely to prescribe as they will get into trouble for it so you just need to convince them you will be fine on a drug.

And yet we have anxiety disorder sufferers on here alone who have found Fluoxetine has helped them.

My point earlier was that whilst licencing may not cover prescribing for anxiety, other local guidelines may be in place to instruct GP's that they can use them. Therefore GP's have the protection of the NHS and are not strictly off labeling.

Preg is a drug of abuse. It is abused by substance misusers and in prisons. They will use anything to get high, they mix it with all sorts and take far higher doses than prescribed for that reason. You can't base anything on what people like that will do. GP's can monitor what is being prescribed.

Yes, Preg may become a Class C. Benzodiazapenes are already controlled substances and this has no impact on prescribing. The cases portrayed in the media about this drug tend to be by substance misusers, not anxiety disorder sufferers.

There are plenty of drugs that can be misused. The issue is stopping access by those who just want to get high. People like the anxiety sufferer on another forum should not be used to label all of us, which I'm sure you aren't. Anxiety sufferers can already be substance misusers too hence why the NHS restricts use of a drug like this. Some will slip through though.

These cases are not compare able. And my point about Buckinghamshire was covering epilepsy too.

Again remember the bias issue. You can't generalise based on the anecdotal reports on an anxiety forum. This place is largely the negatives because like I said, who can be bothered to go around these places saying everything went well?

It's best to let the frustration go in one ear and out of the other rather than let it bother you. When you feel you can't take anymore you ate given a drug that takes months to help, often makes you even worse for 4-6 weeks or worse, like those who end up sectioned due to them. Don't you think people will be struggling so they talk about their feelings? It would be incredibly naive to expect them to just shrug things off.

Having a drug that worked would be great. I was totally naive about meds when I first started with anxiety. My GP lied about the side effects and didn't inform me about how they work. Nowadays I'm well informed so my expectations are more reasonable. I've been far from happy about the poor service from my GP, which is my right.

Again, beware bias. I would have been one of those unhappy people at the start. Now I know all of these meds are a gamble, I know I'm going to be a guinea pig and not necessarily just because of my GP's lack of knowledge.

The NHS is irrelevant. US members complain about their doctors too. Since I can't recall seeing a thread involving Bupa since I came here, I don't expect to see complaints about them but it would be wrong to assume they don't cause the same frustrations since the issue is largely the meds and how no doctor has a clue how you will respond.

[pulisa]

I agree. it's very much a "suck it and see" approach. My daughter developed severe neutropenia on all the SSRIs which caused her to have to be put into isolation until her count rose again after going cold turkey. Even in the face of her count going back to normal each time after one week the drugs companies didn't want to know. I would get a phone call in the early hours from the path lab so I knew it was serious.

[panic_down_under]

My daughter developed severe neutropenia on all the SSRIs

Neutropenia isn't only a potential, though rare, SSRI side-effect, but many antidepressants and other psych meds can cause low white cell counts, as can many other medications. In fact the list of meds which have it listed as a side-effect is as long as your arm.


I have the opposite problem, my WBC cell is almost into leukemia territory. Has been for at least 50 years. On the plus side, the last time I had the flu was in 1987.