View Full Version : Imipramine, have I made the right choice?
So after being on SSRIs for about 15 years it seems that they just don't work for me anymore. I recently realised I was getting mild panic attacks, especially at night time partly due to being worried I wouldn't sleep as I'd had a bad bout if insomnia.
I read imipramine was good for panic attacks and asked if I could switch From sertaline. Now I have seen that imipramine isn't sedating and can cause insomnia. So now I'm worried I should have asked for something different but I have only been in the imipramine 4 days and have been switching meds every six months or so before I decided to quit ssris. Should I just wait it out and see? As if the panic attacks and anxiety are what was causing my insomnia (I think it is the root cause) if I treat the root cause the insomnia may disappear?
Edit to add I am due a 3 week catch up with my docs on the 21st of February.
panic_down_under
04-02-20, 11:36
I read imipramine was good for panic attacks and asked if I could switch From sertaline.
Imipramine was the 'gold standard' panic disorder med until the SSRIs came along. It didn't go out of favour because the SSRIs were more effective, they are often less so, but because the newer meds were perceived to be safer in overdose. Turns out that isn't true for all of them, although sertraline is one that is.
Now I have seen that imipramine isn't sedating and can cause insomnia
Which is also generally true of the SSRIs and SNRIs. Indeed, insomnia is their most common side-effect, though some do have a paradoxical response.
If insomnia becomes an ongoing issue ask your GP to prescribe a small dose of mirtazapine, say half a 15mg tablet. Mirtazapine is an AD which at low doses functions mostly as a very sedating antihistamine. It becomes progressively less sedating at higher doses. Imho, it is a better bet than benzodiazepines and the 'Z' class hypnotics for sleep as tolerance to their sedation tends to build quickly.
So now I'm worried I should have asked for something different but I have only been in the imipramine 4 days and have been switching meds every six months or so before I decided to quit ssris. Should I just wait it out and see? As if the panic attacks and anxiety are what was causing my insomnia (I think it is the root cause) if I treat the root cause the insomnia may disappear?
There is a very good chance imipramine will work for you, but as with all ADs, there are no guarantees. All you can do is give it a shot and keep fingers crossed.
Fwiw, imipramine was the first AD I was prescribed for PD and it was very effective although I had to take a lot of it to get an optimal response, but that has been the case with most ADs I've taken. I was on 300-350mg for 7-8 years, with a few breaks during that time.
Imipramine was the 'gold standard' panic disorder med until the SSRIs came along. It didn't go out of favour because the SSRIs were more effective, they are often less so, but because the newer meds were perceived to be safer in overdose. Turns out that isn't true for all of them, although sertraline is one that is.
Which is also generally true of the SSRIs and SNRIs. Indeed, insomnia is their most common side-effect, though some do have a paradoxical response.
If insomnia becomes an ongoing issue ask your GP to prescribe a small dose of mirtazapine, say half a 15mg tablet. Mirtazapine is an AD which at low doses functions mostly as a very sedating antihistamine. It becomes progressively less sedating at higher doses. Imho, it is a better bet than benzodiazepines and the 'Z' class hypnotics for sleep as tolerance to their sedation tends to build quickly.
There is a very good chance imipramine will work for you, but as with all ADs, there are no guarantees. All you can do is give it a shot and keep fingers crossed.
Fwiw, imipramine was the first AD I was prescribed for PD and it was very effective although I had to take a lot of it to get an optimal response, but that has been the case with most ADs I've taken. I was on 300-350mg for 7-8 years, with a few breaks during that time.
Thanks for the reply PDU.
I feel a lot better for reading that. I'm not sure if my doc will prescribe mirtazapine alongside what I'm on but it can't hurt to ask.
My son's psychiatrist said that men often got a better response from TCAs than SSRI/SNRIs although I've no idea how accurate this is. I really hope you get some benefit from your new med and it's certainly worth trying. I always found SSRIs horribly activating and could only tolerate a sub-therapeutic dose.
panic_down_under
04-02-20, 22:16
I'm not sure if my doc will prescribe mirtazapine alongside what I'm on but it can't hurt to ask.
Are you on any other meds besides imipramine?
There are no issues taking mirtazapine with imipramine, although your GP's drug interaction checker may, incorrectly, highlight a potential risk of serotonin syndrome/toxicity (SS/ST). To quote one of the two leading SS/ST experts, Dr Ken Gillman (http://scholar.google.com.au/citations?user=ea6KeD0AAAAJ&hl=en):
"As I have pointed out before, drugs like bupropion and mirtazapine, that have no significant serotonergic activity, are no more likely to cause ST than is vitamin C. This scenario has already been enacted, over a decade, with the antidepressant mirtazapine, which was claimed, erroneously, to have serotonergic activity. Many poor quality case reports of ST with mirtazapine were published. This probably led to misdirected treatment of overdoses, some of which may have caused morbidity. It took several reviews to correct this error and establish that mirtazapine cannot cause ST"
PK Gillman, 2010 PDF (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3550296/pdf/13181_2010_Article_84.pdf). See also: A systematic review of the serotonergic effects of mirtazapine in humans (https://onlinelibrary.wiley.com/doi/abs/10.1002/hup.750)...
And lest there be any doubt, the other leading expert, Ian M. Whyte, whose team at the Hunter Toxicology group wrote the SS/ST diagnostic criteria, agrees (5-HT=serotonin):
"In some cases this has led to reports of serotonin toxicity for drugs that, from well-defined receptor binding studies, are unlikely to cause increased levels of CNS 5-HT. Important examples include the 5-HT2A receptor antagonist olanzapine and the 5-HT receptor antagonist mirtazapine."
The Hunter Serotonin Toxicity Criteria (https://academic.oup.com/qjmed/article/96/9/635/1522590)
Moreover, as Ian Whyte points out, mirtazapine is a serotonin 5-HT2a receptor antagonist. They can block (https://www.ncbi.nlm.nih.gov/pubmed/20655983) the body temperature spike which does the damage in SS/ST although in humans the recommended treatments (http://www.psychotropical.com/treatment-of-serotonin-toxicity) are the more potent 5-HT2a antagonists cyproheptadine and chlorpromazine.
WiseMonkey
04-02-20, 23:51
My son's psychiatrist said that men often got a better response from TCAs than SSRI/SNRIs although I've no idea how accurate this is. I really hope you get some benefit from your new med and it's certainly worth trying. I always found SSRIs horribly activating and could only tolerate a sub-therapeutic dose.
That's interesting pulisa, I can only take TCA's the others have me climbing the walls (likely due to autoimmune activity). Some years ago a Dr told me that certain types of AD's can suit family members. When my dad got depression in his late 60's they put him on Doxepin which suited me too. He did quite well on it.
My son seems able to tolerate most ADs (currently on 300mg venlafaxine) but my daughter develops severe neutropenia on all SSRIs except sertraline which is ineffective at its highest dose. I can take TCAs but SSRIs have caused a couple of hospitalisations. Our brains are very complicated, aren't they?!
I'd certainly opt for a TCA over any other newer drug.
Are you on any other meds besides imipramine?
There are no issues taking mirtazapine with imipramine, although your GP's drug interaction checker may, incorrectly, highlight a potential risk of serotonin syndrome/toxicity (SS/ST). To quote one of the two leading SS/ST experts, Dr Ken Gillman (http://scholar.google.com.au/citations?user=ea6KeD0AAAAJ&hl=en):
"As I have pointed out before, drugs like bupropion and mirtazapine, that have no significant serotonergic activity, are no more likely to cause ST than is vitamin C. This scenario has already been enacted, over a decade, with the antidepressant mirtazapine, which was claimed, erroneously, to have serotonergic activity. Many poor quality case reports of ST with mirtazapine were published. This probably led to misdirected treatment of overdoses, some of which may have caused morbidity. It took several reviews to correct this error and establish that mirtazapine cannot cause ST"
PK Gillman, 2010 PDF (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3550296/pdf/13181_2010_Article_84.pdf). See also: A systematic review of the serotonergic effects of mirtazapine in humans (https://onlinelibrary.wiley.com/doi/abs/10.1002/hup.750)...
And lest there be any doubt, the other leading expert, Ian M. Whyte, whose team at the Hunter Toxicology group wrote the SS/ST diagnostic criteria, agrees (5-HT=serotonin):
"In some cases this has led to reports of serotonin toxicity for drugs that, from well-defined receptor binding studies, are unlikely to cause increased levels of CNS 5-HT. Important examples include the 5-HT2A receptor antagonist olanzapine and the 5-HT receptor antagonist mirtazapine."
The Hunter Serotonin Toxicity Criteria (https://academic.oup.com/qjmed/article/96/9/635/1522590)
Moreover, as Ian Whyte points out, mirtazapine is a serotonin 5-HT2a receptor antagonist. They can block (https://www.ncbi.nlm.nih.gov/pubmed/20655983) the body temperature spike which does the damage in SS/ST although in humans the recommended treatments (http://www.psychotropical.com/treatment-of-serotonin-toxicity) are the more potent 5-HT2a antagonists cyproheptadine and chlorpromazine.
Hi, yes I am on promazine as well at the moment. Thanks for that info I will print it off and take it with me to my next appointment. I didn't sleep well last night again :-(
My son's psychiatrist said that men often got a better response from TCAs than SSRI/SNRIs although I've no idea how accurate this is. I really hope you get some benefit from your new med and it's certainly worth trying. I always found SSRIs horribly activating and could only tolerate a sub-therapeutic dose.
That's interesting. Thank you, I'm hoping so too. I've had enough of changing meds. I do seem to be getting some of my libido back already.
panic_down_under
05-02-20, 10:46
Hi, yes I am on promazine as well at the moment.
And you still can't sleep? In the U.S. promazine is only registered as a veterinary drug often used to tranquilize horses (http://stablemade.com/hproducts/drugs/ace.htm) for surgery. If it isn't helping you sleep then mirtazapine is unlikely to do so.
And you still can't sleep? In the U.S. promazine is only registered as a veterinary drug often used to tranquilize horses (http://stablemade.com/hproducts/drugs/ace.htm) for surgery. If it isn't helping you sleep then mirtazapine is unlikely to do so.
It's only been since I started imipramine on Friday last week and I've been on promazine about 18 months now. Perhaps I've built up a tolerance?
panic_down_under
05-02-20, 20:59
It's only been since I started imipramine on Friday last week and I've been on promazine about 18 months now. Perhaps I've built up a tolerance?
Perhaps, although tolerance is usually slow to develop.
I woke up every hour last night. I am starting to wonder if it's from withdrawing from 100mg of sertraline in 2 weeks. I had similar problems when I came off citalopram.
My doctor wants me to wait it out a few more weeks.
panic_down_under
07-02-20, 02:44
I woke up every hour last night. I am starting to wonder if it's from withdrawing from 100mg of sertraline in 2 weeks. I had similar problems when I came off citalopram.
Possibly. Was withdrawing that quickly your idea, or your doctor's? If the latter, s/he deserves a swift kick to the posterior, imho. Way too fast, plus unnecessary if switching to another AD (moving to/from MAOIs is the exception). Most people tolerate a reasonably quick cross-taper better than weaning off one AD before starting another and usually get faster results.
My doctor wants me to wait it out a few more weeks.
Agreed. You're closer to a resolution with each passing day. Quitting imipramine to try something else would put you back to square one and will probably be no easier than what you're experiencing now.
Possibly. Was withdrawing that quickly your idea, or your doctor's? If the latter, s/he deserves a swift kick to the posterior, imho. Way too fast, plus unnecessary if switching to another AD (moving to/from MAOIs is the exception). Most people tolerate a reasonably quick cross-taper better than weaning off one AD before starting another and usually get faster results.
Agreed. You're closer to a resolution with each passing day. Quitting imipramine to try something else would put you back to square one and will probably be no easier than what you're experiencing now.
It was the doctors idea. He wanted me to go from 100 mg to 50 mg for a week then 50 every other day. I didn't do that I dropped to 50 and I cross tapered at 25mg for 5 days since I stopped sertraline my sleep seems to have improved. My anxiety seems to be settling except for the odd random anxiety attacks. But it's looking better. Thanks for your advice , it has helped having someone as knowledgeable as yourself giving me decent advice.
panic_down_under
10-02-20, 08:02
It was the doctors idea. He wanted me to go from 100 mg to 50 mg for a week then 50 every other day.
That's way too fast and this idea of tapering by skipping doses is nutz, imho, especially with relatively short half-life ADs such as sertraline. It tends to set up a yo-yo affect which can be very disturbing. And it's completely unnecessary as accurate pill-cutters are readily available from most pharmacies. The only AD for which it is useful is the SNRI duloxetine which comes in a limited range of doses in slow-release capsules which can't be 'cut' and even them I think cross-tapering to fluoxetine and tapering off it is a better way of quitting.
I was on Trimipramine for ten years. It was extremely sedating, I could easily sleep for 10 hours a night. I had to come off it because it became too expensive. I’m now on Venlafaxine, an SNRI and I’m happier not to be spending half my life asleep! Trimipramine also gave me palpitations and arrhythmia. All of these drugs have side effects, it’s just a case of finding one that treats your problems most effectively and doesn’t cause unbearable new ones. Good luck.
panic_down_under
10-02-20, 12:17
I was on Trimipramine for ten years. It was extremely sedating, I could easily sleep for 10 hours a night.
Unlike the SSRIs which are all alike in their basic action, the TCAs differ widely in the affect on receptors and reuptake transporters. Trimipramine has only a weak impact on the serotonin transporters and a very weak affect on noradrenaline, aka norepinephrine pathways. Its strongest activity is on the histamine H1 receptor. It is arguably not an antidepressant at all, but an antihistamine which lessens anxiety by sedation, rather than by hippocampal neurogenesis. Doxepin and mirtazapine are much the same. OTOH, imipramine is a very potent serotonin reuptake inhibitor, and potent NA inhibitor, much more potent than venlafaxine which is really only a SSRI.
Hi PDU, hope you are well. This is a little off topic as I want to ask your opinion on a different antidepressant in light of your remark regarding Imipramine that Its strongest activity is on the histamine H1 receptor. It is arguably not an antidepressant at all, but an antihistamine which lessens anxiety by sedation, rather than by hippocampal neurogenesis. Do you think that Mirtazapine works in this way also? I know it has a powerful effect on the H1 histamine receptor, but I was wondering if that is all it basically does?
panic_down_under
10-02-20, 22:38
Hi PDU, hope you are well. This is a little off topic as I want to ask your opinion on a different antidepressant in light of your remark regarding Imipramine that Its strongest activity is on the histamine H1 receptor. It is arguably not an antidepressant at all, but an antihistamine which lessens anxiety by sedation, rather than by hippocampal neurogenesis.
That comment was about trimipramine, not imipramine. Different meds.
[/I]Do you think that Mirtazapine works in this way also? I know it has a powerful effect on the H1 histamine receptor, but I was wondering if that is all it basically does?
Pretty much, imho. And I'm not the only one (https://psychotropical.com/mirtazapine-a-paradigm-of-mediocre-science/) to think this (see also (https://psychotropical.com/mirtazapine-dubious-evidence/)).
Many thanks for that reply and information which I have just skimmed through now but will read in detail tomorrow.
And sorry PDU, I realized afterwards that I had referred to Imipramine instead of Trimipramine - can I borrow your D'oh! :)
Quick update. My dosage was increased to 50mg yesterday. So far no more issues and I have been sleeping quite well. I have noticed I seem to experience more highs and lows emotionally than I have ever on ssris.
panic_down_under
22-02-20, 22:07
Quick update. My dosage was increased to 50mg yesterday. So far no more issues and I have been sleeping quite well.
The TCAs tend to produce milder initial side-effects than the SSRIs/SNRIs, however, they tend to have more ongoing ones, mostly dry-mouth and constipation which can be managed. Insomnia is also much less likely with TCAs than SSRIs/SNRIs because TCAs are mild to powerful antihistamines.
I have noticed I seem to experience more highs and lows emotionally than I have ever on ssris.
It is early days and you're on a low dose so I wouldn't read too much into this. Some of it could also be a rebound from sertraline if it had dampened emotions.
I have a six month baby at home but I have just noticed I feel much happier generally than I have in a long time. But if I see something sad on TV for instance it just seems to have more of an effect on me. I do put it down to the emotional blunting from sertraline and duloxetine earlier.
I have noticed I have more vivid dreams also.
I see the recommend dose is 125mg and my doctor is only increasing it 25 mg every 2 weeks and I'm a big guy as well coming in at 260lbs. It's going to take a while before I get the full effect.
panic_down_under
26-02-20, 11:21
I do put it down to the emotional blunting from sertraline and duloxetine earlier.
Possibly. Some ADs may have that affect on some people. Switching to another AD will usually resolve the issue, however, some prefer the blunting.
I have noticed I have more vivid dreams also.
I suspect the dreams don't actually change. That they are just as vivid most of the time, but ADs may lighten REM sleep enough for them to intrude into conscious awareness. I used to have some beauties on imipramine. The full DeMille extravagances in widescreen Technicolor with surround sound...well if DeMille was on crack, some were really weird! Haven't taken it for over 25 years, but I still miss them.
I see the recommend dose is 125mg and my doctor is only increasing it 25 mg every 2 weeks and I'm a big guy as well coming in at 260lbs. It's going to take a while before I get the full effect.
Patience is a virtue and that applies double where ADs are concerned. Better to go slow to minimize the initial side-effects than to rush it. The usual effective dose range is 100-200mg, but a few may need more. I was on 350mg for a while.
Body weight doesn't matter much. Antidepressants have no direct effect on anxiety, or depression in the way say aspirin has on a headache. They work by stimulating the growth of new brain cells (http://www.ncbi.nlm.nih.gov/pmc/articles/PMC60045/) (neurogenesis) to replace cells killed, or prevented from growing by high brain stress hormone levels. The therapeutic response is produced by these new cells and the stronger interconnections they forge, not the meds directly, and they take time to bud, grow and mature. For a more detailed explanations see: Depression and the Birth and Death of Brain Cells (PDF (https://www.americanscientist.org/sites/americanscientist.org/files/20057610584_306.pdf)) and How antidepressant drugs act (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3025168/).
Apologies I haven't posted for a while. I've have been really busy. Thought I would post a quick update. So I have felt a lot better than I did when I was on sertraline, the panic attacks have gone but the general anxiety and my temper are bubbling away underneath. Although I have not felt as good as when I responded to citalopram.
I would like to increase the dosage but the doctor who prescribed it is adamant 100mg is the maximum dose for imipramine, should I ask for a second opinion? I don't want to keep changing meds..
panic_down_under
20-07-20, 23:44
I would like to increase the dosage but the doctor who prescribed it is adamant 100mg is the maximum dose for imipramine,
Which is why it comes in tablets up to 150mg! :sad: The usual starting dose for depression in healthy adults is 75mg with a maximum recommended dose is 200mg as an outpatient, 300mg under medical supervision in hospital (see British National Formulary: imipramine (https://bnf.nice.org.uk/drug/imipramine-hydrochloride.html)). I took 350mg for many months without issue and was on 300mg for years. I suggest you take doses above 100mg in 2-3 divided doses.
should I ask for a second opinion?
Definitely
Which is why it comes in tablets up to 150mg! :sad: The usual starting dose for depression in healthy adults is 75mg with a maximum recommended dose is 200mg as an outpatient, 300mg under medical supervision in hospital (see British National Formulary: imipramine (https://bnf.nice.org.uk/drug/imipramine-hydrochloride.html)). I took 350mg for many months without issue and was on 300mg for years. I suggest you take doses above 100mg in 2-3 divided doses.
Definitely
I had a telephone consultation earlier and the doctor I spoke to advised she can put the dosage up to 150mg until I 'stabilise' then they bring me back to 100mg. She told me they are not trained with imipramine as it's an old drug, the secondary care team would do that. Looking at my record the only one I haven't tried shes familiar with is venlaflaxine. I didn't do great on duloxetine, so I was wary of trying it. So I agreed to go to 150mg of imipramine and then asked if I'm happy in 6 weeks would she speak to the secondary care team. She was happy to try this.
The imipramine has helped just not enough and the side effects have been minimal. The only one that's bugging me is the dry mouth. Better than having no sex drive and anorgasmia when I am actually in the mood.
panic_down_under
21-07-20, 13:37
I had a telephone consultation earlier and the doctor I spoke to advised she can put the dosage up to 150mg until I 'stabilise' then they bring me back to 100mg. She told me they are not trained with imipramine as it's an old drug,
This is why they have dosing guides such as the Formulary! They only need to know how to read the Queen's <expletive> English! Sigh. :mad:
I haven't tried shes familiar with is venlaflaxine. I didn't do great on duloxetine, so I was wary of trying it.
Not a fan of venlafaxine. Despite what it says on the tin, it is only a SSRI and while it might work it has a number of potential risks so you might as well try a few plain old SSRIs to see if they'll work first.
What was the problem with duloxetine? It is usually not a bad AD once stabilized on it, but the initial side-effects can be rough, as can weaning off it although venlafaxine is often worse.
The imipramine has helped just not enough and the side effects have been minimal. The only one that's bugging me is the dry mouth.
This does tend to ease over time, although this isn't a guarantee. There are things you can do (https://www.mayoclinic.org/diseases-conditions/dry-mouth/expert-answers/dry-mouth/faq-20058424) to minimise it and Biotene (https://www.biotene.co.uk/) make a range of gels, toothpastes and mouthwashes to ease the discomfort. There may be other brand too. Your chemist should be able to advise you on what is available, although they may be cheaper from Amazon and Ebay.
Better than having no sex drive and anorgasmia when I am actually in the mood.
Long may that continue, though it is still a possibility. Sexual dysfunction tends to be less of a problem with TCAs than SSRIs/SNRIs, but it can still arise. If it does you may find my tips (http://www.nomorepanic.co.uk/showpost.php?p=1695131&postcount=7) useful.
This is why they have dosing guides such as the Formulary! They only need to know how to read the Queen's <expletive> English! Sigh. :mad:
Not a fan of venlafaxine. Despite what it says on the tin, it is only a SSRI and while it might work it has a number of potential risks so you might as well try a few plain old SSRIs to see if they'll work first.
What was the problem with duloxetine? It is usually not a bad AD once stabilized on it, but the initial side-effects can be rough, as can weaning off it although venlafaxine is often worse.
This does tend to ease over time, although this isn't a guarantee. There are things you can do (https://www.mayoclinic.org/diseases-conditions/dry-mouth/expert-answers/dry-mouth/faq-20058424) to minimise it and Biotene (https://www.biotene.co.uk/) make a range of gels, toothpastes and mouthwashes to ease the discomfort. There may be other brand too. Your chemist should be able to advise you on what is available, although they may be cheaper from Amazon and Ebay.
Long may that continue, though it is still a possibility. Sexual dysfunction tends to be less of a problem with TCAs than SSRIs/SNRIs, but it can still arise. If it does you may find my tips (http://www.nomorepanic.co.uk/showpost.php?p=1695131&postcount=7) useful.
Apparently according to the doctor I spoke to they follow the NICE guidelines.
I can't remember so well when I was on duloxetine, if I remember correctly I spoke to a doctor that said it sounded like it was making me depressed however I was going through a hard time at work and had a bereavement around that time. I do remember being spaced out and lethargic as hell a lot on it plus the usual sexual dysfunction and emotional blunting. I think if they won't budge on the 150mg imipramine it might be worth trying it again, since a lot of those stressors I've had at the time are resolved.
panic_down_under
22-07-20, 00:00
Apparently according to the doctor I spoke to they follow the NICE guidelines.
The BNF dosing guideline I link to earlier suggests they aren't as the Formulary is produced by NICE.
I can't remember so well when I was on duloxetine, if I remember correctly I spoke to a doctor that said it sounded like it was making me depressed however I was going through a hard time at work and had a bereavement around that time.
Some do have paradoxical reactions to an AD and become more depressed so it is possible the doctor was correct.
I do remember being spaced out and lethargic as hell a lot on it plus the usual sexual dysfunction and emotional blunting. I think if they won't budge on the 150mg imipramine it might be worth trying it again, since a lot of those stressors I've had at the time are resolved.
If 150mg works and 100mg doesn't then they'd be crazy to insist you return to the lower dose. Get another opinion if it comes to that.
The BNF dosing guideline I link to earlier suggests they aren't as the Formulary is produced by NICE.
Some do have paradoxical reactions to an AD and become more depressed so it is possible the doctor was correct.
If 150mg works and 100mg doesn't then they'd be crazy to insist you return to the lower dose. Get another opinion if it comes to that.
It is very concerning that they seem to be pushing SSRI/SNRIs only. They mentioned mirtazapine, which I have tried but came off as it stopped working for my anxiety, although it completely knocked me out at night, which is great as I've suffered on and off with insomnia my whole life.
The doctor did say of I was happy at 150mg she would speak to the secondary care team about me staying on the imipramine.
panic_down_under
22-07-20, 12:38
It is very concerning that they seem to be pushing SSRI/SNRIs only.
Because most GPs and psychiatrists qualified after these became available in the later 1980s and they have little experience of anything else. They've been told SSRIs and SNRIs are newer, better, safer ADs with less side-effects than TCAs and MAOIs. They are certainly newer, but *arguably TCAs and MAOIs are generally more effective and some SSRIs and SNRIs are no safer than the older meds. But they do generally have fewer ongoing side-effects, however, the common ongoing TCA side-effects such as dry-mouth and constipation are manageable and they generally produce less severe initial side-effects and withdrawal issues when quitting.
* the effectiveness of meds is calculated by the number of patients that need to be treated to get one good outcome - Numbers to Treat (NTT). The better a drug's efficacy the lower the number. De Lima MS (https://pubmed.ncbi.nlm.nih.gov/12495364/), 2003 found the NTT for MAOIs = 2.9, TCAs = 4.3, SSRIs = 5.1. Arroll B (https://pubmed.ncbi.nlm.nih.gov/16189062/), 2005 came up with a similar result: TCAs = 4, SSRIs = 6.
They mentioned mirtazapine, which I have tried but came off as it stopped working for my anxiety, although it completely knocked me out at night, which is great as I've suffered on and off with insomnia my whole life.
Mirtazapine isn't really an antidepressant, but a potent antihistamine. It seems to treat anxiety mostly by sedation.
Because most GPs and psychiatrists qualified after these became available in the later 1980s and they have little experience of anything else. They've been told SSRIs and SNRIs are newer, better, safer ADs with less side-effects than TCAs and MAOIs. They are certainly newer, but *arguably TCAs and MAOIs are generally more effective and some SSRIs and SNRIs are no safer than the older meds. But they do generally have fewer ongoing side-effects, however, the common ongoing TCA side-effects such as dry-mouth and constipation are manageable and they generally produce less severe initial side-effects and withdrawal issues when quitting.
* the effectiveness of meds is calculated by the number of patients that need to be treated to get one good outcome - Numbers to Treat (NTT). The better a drug's efficacy the lower the number. De Lima MS (https://pubmed.ncbi.nlm.nih.gov/12495364/), 2003 found the NTT for MAOIs = 2.9, TCAs = 4.3, SSRIs = 5.1. Arroll B (https://pubmed.ncbi.nlm.nih.gov/16189062/), 2005 came up with a similar result: TCAs = 4, SSRIs = 6.
Mirtazapine isn't really an antidepressant, but a potent antihistamine. It seems to treat anxiety mostly by sedation.
So I had a bit of an argument with the doctors today. They had advised me that the psychiatrist at the hospital had told them to restart me on sodium valproate (long story but I've been trying to get myself of diazepam and had been getting tremors and insomnia unsurprisingly, plus they suspected I may be bipolar, I'm not it's panic attacks) then told me I couldn't have it because I am taking imipramine, even though it was ok apparently to take valproate with duloxetine. So I've been referred back to the psychiatrist which mean its probably going to be a while before I get an appointment..
panic_down_under
23-07-20, 12:36
So I had a bit of an argument with the doctors today. They had advised me that the psychiatrist at the hospital had told them to restart me on sodium valproate (long story but I've been trying to get myself of diazepam and had been getting tremors and insomnia unsurprisingly, plus they suspected I may be bipolar, I'm not it's panic attacks) then told me I couldn't have it because I am taking imipramine, even though it was ok apparently to take valproate with duloxetine.
There is a minor drug interaction between sodium valproate and imipramine because of the enzymes that metabolise both which might require some rebalancing of the doses, but that shouldn't be that difficult especially at the relatively low imipramine dose you're on. I suspect this is another symptom of ignorance about TCAs. BTW-sodium valproate + duloxetine has even more potential problems! Anyway, there are alternatives that could be tried for easing BZD withdrawal although I think your psychiatrist will just adopt a quizzical expression while getting out his prescription pad for sodium valproate if he deems it necessary.
There is a minor drug interaction between sodium valproate and imipramine because of the enzymes that metabolise both which might require some rebalancing of the doses, but that shouldn't be that difficult especially at the relatively low imipramine dose you're on. I suspect this is another symptom of ignorance about TCAs. BTW-sodium valproate + duloxetine has even more potential problems! Anyway, there are alternatives that could be tried for easing BZD withdrawal although I think your psychiatrist will just adopt a quizzical expression while getting out his prescription pad for sodium valproate if he deems it necessary.
Ahhh that makes sense.
What alternatives do you have in mind?
panic_down_under
24-07-20, 00:48
What alternatives do you have in mind?
One of the other anticonvulsants, carbamazepine, although it has much the same drug interaction issues as sodium valproate increasing imipramine plasma levels by slowing the rate it is metabolised so the imipramine dose may need to be reduced. However, it is likely to be a more effective med. Pregabalin (Lyrica) is also usually effective, but will also slow imipramine breakdown.
Thanks for the advice PDU, I'll bring it up at the psychiatrists appointment. I can see their being an issue in some way as they don't seem to like the fact that I'm telling them what I should be taking and the fact I've been taking diazepam for years without a prescription.
panic_down_under
27-07-20, 12:30
I can see their being an issue in some way as they don't seem to like the fact that I'm telling them what I should be taking
Yeah, they tend not to like proactive patients. Makes it harder to treat us like mushrooms. But while I think carbamazepine has the edge if they insist on sodium valproate I'd wouldn't make much of a fuss...well actually I would but only because I'm a cantankerous old bugger who likes stirring the pot.
and the fact I've been taking diazepam for years without a prescription.
You really need to consider getting off it once you're stabilised on an effective AD because it hinders AD effectiveness. The BZDs have their place in treating anxiety, but probably not as long-term meds.
Yeah, they tend not to like proactive patients. Makes it harder to treat us like mushrooms. But while I think carbamazepine has the edge if they insist on sodium valproate I'd wouldn't make much of a fuss...well actually I would but only because I'm a cantankerous old bugger who likes stirring the pot.
You really need to consider getting off it once you're stabilised on an effective AD because it hinders AD effectiveness. The BZDs have their place in treating anxiety, but probably not as long-term meds.
I'm hoping they'll do something along those lines, I mean to be honest other than the imipramine I'm on exactly what they prescribed, it's the doctors who won't prescribe the mood stabilizer the psychiatrist prescribed.
I have had some addiction issues in the past but I have really struggled to come off the diazepam for over a year now.
panic_down_under
29-07-20, 12:32
I'm hoping they'll do something along those lines, I mean to be honest other than the imipramine I'm on exactly what they prescribed, it's the doctors who won't prescribe the mood stabilizer the psychiatrist prescribed.
That is 'brave' of them. Have you referred this back to the psychiatrist?
I have had some addiction issues in the past but I have really struggled to come off the diazepam for over a year now.
Now is not the time to try again, but once the new med regime is working it really needs to be tackled. The trick is to formulate a plan and to stick to it. I'm not a Heather Ashton fan, imho she is a very flawed character pushing some dubious ideologies, but the method set out in her manual (https://www.benzo.org.uk/manual/bzsched.htm) is as good a plan as any. I wouldn't take on board anything else claimed on that site. Much of it is male bovine manure based on ignorance, often wilful ignorance, plus more than a little zealotry.
Yes, they have referred me back, I'm not sure how long it will be till I get to see them.
I am familiar with the Ashton method, I have the book "Back to life" it's going to be a challenge as I'm taking zopiclone as well. Stupid as I know it is it is mind you. I do plan on tackling it, I'd like the help of professionals but the drug services where I live are mainly focused on opiates..
Hopefully my sleep and anxiety improve as they've both been pretty bad since I had the dosage increased. I assume this is normal?
Thanks for all your advice, it's been really helpful.
panic_down_under
30-07-20, 13:22
I am familiar with the Ashton method, I have the book "Back to life" it's going to be a challenge as I'm taking zopiclone as well. Stupid as I know it is it is mind you. I do plan on tackling it, I'd like the help of professionals but the drug services where I live are mainly focused on opiates..
One that understands the particular issues with BZDs could be a big help, but I'd be wary about those without considerable experience. The problem is there are two issues that need handling with BZD withdrawal, the effects of the med and the issues arising from the anxiety disorder. It needs a delicate touch, not the bull-in-gate approach often used with opiates, etc. :ohmy:
Hopefully my sleep and anxiety improve as they've both been pretty bad since I had the dosage increased. I assume this is normal?
Unfortunately, yes for both. Serotonin isn't the 'feel good' neurotransmitter of popular myth, anything but as you've discovered (neurotransmitters don't actually have an intrinsic attribute, their action is determined by the receptors they bind too). The increased serotonin activity should begin to drop a couple of weeks after the last dose increase and the heightened anxiety will then usually begin to diminish. The extra serotonin is probably also responsible for the insomnia and imipramine isn't usually sedating enough to override this. Like the anxiety it should diminish after a week, or two as serotonin synthesis and expression drops back to baseline, and below. If it become a problem in the meantime then maybe try an over the counter antihistamine like diphenhydramine found in Nytol tablets and liquid. If that isn't strong enough then ask your doctors for something. A small dose of mirtazapine should do the trick, but their computer may flag a risk of serotonin syndrome. It will be wrong, but you might have trouble convincing them of this because there is so much BS about it even in MHRA, NHS and FDA literature despite the best efforts of syndrome researchers like Ken Gillman and Ian Whyte. :weep:
Thanks for the advice. I had been ok sleeping and the anxiety had calmed down. But I had a tough night last night.
I am going to wait untill everything has settled before I try to withdraw.
I did speak to my doctor last week and they are asking me to speak to them in a two weeks to see how I'm doing. I've not been great but I'd like to give the imipramine a bit longer to work. They did mention paroxetine which is the only SSRI I haven't tried. They said it helps some people who can't sleep because of anxiety, could this potentially be a good shout? Citalopram used to work like a charm for me but I've been off and on it too much I think. Same as I jave with sertraline or have I been off and on SSRI for so long (about 10 years) that none will work?
panic_down_under
05-08-20, 10:56
I did speak to my doctor last week and they are asking me to speak to them in a two weeks to see how I'm doing. I've not been great but I'd like to give the imipramine a bit longer to work.
Given your med history (see below) and the fact you're taking diazepam which inhibits the way ADs work it will likely take any AD longer than usual to kick-in so I'd be planning to give imipramine a good 12 weeks at 150mg to prove itself before drawing any conclusions.
They did mention paroxetine which is the only SSRI I haven't tried. They said it helps some people who can't sleep because of anxiety, could this potentially be a good shout?
Paroxetine has no intrinsic sedative properties and insomnia is one of the most common SSRI side-effects so... That said, if it works well then you sleep patterns are likely to be more settled. But it's too early to be contemplating a med change, imho.
Citalopram used to work like a charm for me but I've been off and on it too much I think. Same as I jave with sertraline or have I been off and on SSRI for so long (about 10 years) that none will work?
There is growing evidence antidepressants may become progressively less effective every time they are stopped and restarted, often requiring higher doses to achieve the previous level of control, or not working at all. They may also produce more severe, and/or different, initial side-effects. Two studies, Amsterdam JD (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5123793/), 2016 and Amsterdam JD (http://www.karger.com/Article/FullText/226611), 2009, found the likelihood of antidepressants working after each restart drops by between 19-25% (see also: Bosman RC (https://www.ncbi.nlm.nih.gov/pmc/articles/pmid/30041180/), 2018; Amsterdam JD (http://www.ncbi.nlm.nih.gov/pubmed/18694599), 2009; Leykin Y (http://www.ncbi.nlm.nih.gov/pubmed/17469884), 2007; Paholpak S (https://www.ncbi.nlm.nih.gov/pubmed/12501907), 2002).
In light of this I suggest you give serious thought to remaining permanently on imipramine, or whatever AD next works well for you. It was a conclusion I reached after having to go back onto ADs for the third time because restarting them was such a pain in the butt (and elsewhere). I've been on a TCA pretty much continually for nearly 30 years now and my brain hasn't turned to mush yet. As a bonus there is good evidence that TCAs and SSRIs can reduce the risk of Alzheimer's dementia and the blood thinning properties of SSRIs and other serotoninergic ADs may also reduce heart attack and ischaemic stroke risk, although they may increase that of the much less common haemorrhagic stroke a little.
Hi panic down under. Thank you for the detailed reply. I plan on giving imipramine a bit more time. I am struggling really bad with my sleep at the moment and sleeping well is something I have massive obsession with. I will be sticking with whatever works well for me permanently I think. I wish I could go back to the time when all I was taking was citalopram and a joint at night ( I started benzos to get off smoke Ng a joint to help me sleep, most stupid decision I've ever made) and was getting 8 hours sleep and holding down a full time job. I feel like I'm losing the fight with my diazepam and zopiclone at the moment.
panic_down_under
07-08-20, 13:49
I am struggling really bad with my sleep at the moment and sleeping well is something I have massive obsession with.
SSRI induced insomnia is a very common initial side-effects. Talk to your GP as it is treatable.
I wish I could go back to the time when all I was taking was citalopram and a joint at night ( I started benzos to get off smoke Ng a joint to help me sleep, most stupid decision I've ever made)
That was jumping from the frying pan into the fire. The THC in cannabis inhibits hippocampi neurogenesis. Just as with alcohol and BZDs cannabis gives the illusion of reducing anxiety while triggering, or reinforcing the very brain changes which produces it and depression. Cannabidiol (CBD) inhibits the deleterious effects of THC, but most of the cannabis sold these days has been selectively breed to maximize THC and lower CBD levels.
and was getting 8 hours sleep and holding down a full time job. I feel like I'm losing the fight with my diazepam and zopiclone at the moment.
Neither is a good sleeping med as tolerance to their sedating effect builds quickly, often within as little as a couple of weeks. I think their only value to you atm is in preventing withdrawal symptoms. Trazodone and mirtazapine are better bets, though even they need to be taken with caution.
Hello again Panic down under. I ended up having to speak to a doctor as I was struggling with the sleep issues caused by the imipramine and I asked if they would give me a low dose of mirtazapine or increase my dosage of promazine. They eventually talked me into tapering on paroxetine, they originally wanted to put me on venlaflaxine which I turned down flat. I feel that with me staring imipramine around 6 months ago that I gave it a fair shot. I find it odd that I've slept great already since I've started it and imipramine gave me insomnia and made my anxiety worse, like they both behaved the exact opposite side effects wise than you would expect.
My main worries now are that I'll return to having no sex drive, emotional blunting and teeth grinding in my sleep.
panic_down_under
13-08-20, 13:05
They eventually talked me into tapering on paroxetine, they originally wanted to put me on venlaflaxine which I turned down flat. I feel that with me staring imipramine around 6 months ago that I gave it a fair shot.
But you've only been on 150mg for 3? weeks which is lot long enough to know if it will work and which probably accounts for the increased insomnia.
I find it odd that I've slept great already since I've started it
How long have you been taking paroxetine?
Given your history with SSRIs hopefully they'll be willing to prescribe up to the maximum 60mg immediate-release/75mg slow-release for at least 12 weeks should it be necessary.
I know what you mean but I have been struggling with insomnia for around 12 weeks on and off. I felt like I was experiencing a caffeine high all the time.
I don't think they'll have an issue with the dosage tbh. They had me on 60mg of duloxetine a bit back and I personally felt it was too high a dosage, it turned me into an a-sexual apathetic mess. So hopefully it doesn't come to that.
panic_down_under
14-08-20, 00:19
I know what you mean but I have been struggling with insomnia for around 12 weeks on and off.
The TCA amitriptyline might have been a good option as it is a much more potent antihistamine which usually aids sleep.
They had me on 60mg of duloxetine a bit back and I personally felt it was too high a dosage, it turned me into an a-sexual apathetic mess.
60mg is the recommended minimum dose for healthy adults with a maximum of 120mg.
I wanted to try amitriptyline and if I don't get much luck with paroxetine, then it maybe one that is worth mentioning to the psychiatrist when I eventually get an appointment.
I've been on paroxetine a week, so I've not fully tapered off imipramine. But so far so good, I feel a lot more relaxed and I haven't been losing my temper like I was a couple of weeks ago.
I'll see if I can dig out my old prescription as I usually store them, but I remember thinking the dosage was high on duloxetine.
For what it's worth I never went over 30 mg on citalopram and I only stopped and changed from that to sertraline because I was worried about the weight gain aspect. In hindsight it was a foolish decision.
I just thought I would post a quick update in regards to how im getting on with paroxetine.
I must admint so far so good, in fact I feel really well at the moment. Not quite good enough that I feel I am ready to tackle the issues with Diazepam or Zopiclone yet (although im not sure there is ever really a good time). But I have managed to get both ack down to the dosages I was originally taking.
The only side effects I have had are the usually with regards to the sex drive although I am taking a low dose of Gingko as I dont fancy upping that too much so early and I have been getting pretty vivid nightmares.
But yeah so far onwards and upwards,
panic_down_under
24-09-20, 13:30
I am taking a low dose of Gingko as I dont fancy upping that too much so early and I have been getting pretty vivid nightmares.
Just a small note of caution, ginkgo is a mild anticoagulant as are SSRIs so watch out for nose and gum bleeding, or an increased susceptibility to bruising as you increase the ginkgo dose. Most won't experience a problem, but...and I'd avoid taking aspirin, or another NSAID painkiller. Paracetamol, aka acetaminophen, would be the better option for minor pain relief.
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