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I am due to meet with my psychiatrist and we have discussed switching to a TCA, as I am suffering from depression and panic…I am currently poly drugged and it has never truly worked. I’m 6 years on and tried to reduce pregabalin, until I hit withdrawal and have been struggling this past 2 and a half months - Any input or chance to discuss my fears and concerns would be most welcomed
Assuming you're in reasonable health with no significant cardiovascular disease you're unlikely to experience significant cardio side-effects even at the maximum recommended TCA dose. For your peace of mind ask your GP to do an ECG/EKG before starting the TCA and then a few weeks after you're stabilised on an effective dose.Quote:
Originally Posted by SideFX
I don’t have any heart problems that I’m aware of but tachycardia scares me so so so much and it’s a huge gamble with my life. Albeit I’m going through severe mornings of depression and anxiety most of the day !!!!! I did once try amitriptyline, whilst on 30mg mirtazapine and 30mg Duluxotine and the first time just felt very very sedated. But when I tried it again still on the above and only a few days later I just wanted it to knock me out, however I experienced extremely high heart rate and was in extreme distress. I have spoken with you before PDU it was years ago and have been through many breakdowns and lots of meds. But never a TCA except for the above experience with amitriptyline and that has made me very fearful of TCA’s - Your thoughts would be welcomed and some guidance on TCA’s too please. Feel free to ask any questions and thank you PDUQuote:
Originally Posted by panic_down_under
Tachycardia is not necessarily life threatening in the short term for a reasonably health person and can be controlled, plus anxiety is itself a risk factor.Quote:
Originally Posted by SideFX
What happened while taking the other meds doesn't mean the same will happen with a TCA alone. Anxiety may also have been a factor. I'm not surprised that the cocktail was very sedating for mirtazapine is a very sedating antihistamine and so is amitriptyline.Quote:
I did once try amitriptyline, whilst on 30mg mirtazapine and 30mg Duluxotine and the first time just felt very very sedated. But when I tried it again still on the above and only a few days later I just wanted it to knock me out, however I experienced extremely high heart rate and was in extreme distress.
...But never a TCA except for the above experience with amitriptyline and that has made me very fearful of TCA's
Given you have panic disorder imipramine (Tofranil) may be the better TCA. It was the 'gold standard' TCA for panic disorder before SSRIs became available and the first AD I was on for PD. The recommended maximum daily dose is 200mg, or up to 300mg for hospital inpatients, however, I seem to require a strong dose to get a good result from ADs and was on 300-350mg for about 5 years. There were no cardiovascular side-effects noted in my annual ECGs.
Fwiw, in one of his books David Healy recounts how imipramine was developed and mentions that its inventor took up to 1,000mg/day while testing it for safety. Back in the 1950s drug trials were an unknown concept, the developers were also the guinea pigs. :ohmy:
Are you still on pregabalin and if so what is the dose? What other medications are you taking?
See above current list of 4 meds PDU any thoughts pal ???Quote:
Originally Posted by panic_down_under
Sigh :mad: Your doctor/s seem to be from the 'kitchen sink' school of prescribing. Just keep on throwing meds at the problem until hopefully they strike the 'magic' combination that cures all the patient's problems. It never works. In large part because there usually isn't any rhyme or reason behind the meds and doses selected. :sad: For example, what is the point in prescribing both diazepam and pregabalin which do essentially the same thing. Why not just increase the dose of one of them until or works and if it doesn't within its dose range discontinue it (and yes, I understand pregabalin was apparently prescribed to enable you to tolerate vortioxetine which is another crazy idea, imunho!).Quote:
Originally Posted by SideFX
I have no idea whether imipramine is readily available in the UK. I'd be surprised if it isn't, but clomipramine (Anafranil) would be my second choice. Like imipramine is is only a weak antihistamine.Quote:
With regard to imipramine I'm not sure how easy it is to get from UK pharmacies I know Amatrip and Clompit are easy to get
Having a close relative who did well on a med does improve the odds of it working for you though it isn't a guarantee. She might have done even better without the lorazepam.Quote:
My mum was on imipramine and lorazepam for nearly 3 decades and she was fine with them
I suspect the only med in your cocktail that is actually doing much is the pregabalin which has me wondering how much of the withdrawal symptoms were actually just the dose dropping below its therapeutic window.Quote:
As I have tried reducing pregabalin and went into huge withdrawal and been up dosing with minimal success
You won't need to come of mirtazapine, but I doubt it is actually doing much so I don't see the point of being on it. But that's an issue for another day. Yes, you will need to come off vortioxetine (Trintellix aka Brintellix). According to the NHS guideline, switching to imipramine can be done either by a cross-taper over 2-4 weeks, or by stopping vortioxetine and then starting imipramine after some days. Given the choice I'd do the cross-taper, but I suspect the Pdoc will be more comfortable with the second option [Edit: on reflection given your previous experience with amitriptyline tapering off vortioxetine before starting imipramine is probably the wiser choice]. For clomipramine you will need to taper off vortioxetine and then start on the TCA.Quote:
I am thinking do I need to come off Mirt and Brint to try a TCA
Imo, there also needs to be consideration given to discontinuing the diazepam as it is almost certainly inhibiting the effectiveness of vortioxetine to some degree and will have the same effect on the TCA too [1]. How much I can't say as while diazepam and the other benzodiazepines do block neurogenesis, the mechanism by which ADs (also therapy) work, pregabalin may have some protective effect on this by speeding up the maturation of the new brain cells the ADs stimulate into growth. Just how much pregabalin might be countering the effects of diazepam I can't say, but the sooner you come off it the better, although I'd wait until you're stabilised on the TCA as changing two meds at the same time is a bad idea as you can't be sure which might be causing any problems that arise.
Unfortunately, there are only two ADs which do not usually cause sexual dysfunction, bupropion (Wellbutrin) and trazodone. Bupropion is by far the most stimulating AD, far too stimulating for most with anxiety disorders, though some do well on it. Trazodone might be worth considering at some later date.Quote:
Reason for stopping the above, always sexual dysfunction!!!
There are ways of reducing the impact of sexual dysfunction.
References:
[1]
Boldrini M, Butt TH, Santiago AN, et al. (2014)
Benzodiazepines and the potential trophic effect of antidepressants on dentate gyrus cells in mood disorders.
Int J Neuropsychopharmacol. Dec;17(12):1923-33 (Abstract | Full text)
Sun Y, Evans J, Russell B, et al (2013)
A benzodiazepine impairs the neurogenic and behavioural effects of fluoxetine in a rodent model of chronic stress.
Neuropharmacology. Sep;72:20-8 (Abstract)
Song J, Zhong C, Bonaguidi MA, et al (2012)
Neuronal circuitry mechanism regulating adult quiescent neural stem-cell fate decision.
Nature. Sep 6;489(7414):150-4 (Article | Study full text)
Wu X, Castren E. (2009)
Co-treatment with diazepam prevents the effects of fluoxetine on the proliferation and survival of hippocampal dentate granule cells.
Biol Psychiatry. Jul 1;66(1):5-8 (Abstract)
See also: the 'Ugly' part of Benzodiazepines: The Good, The Bad, and the Ugly.
!!!Quote:
Originally Posted by panic_down_under
There are only two potential consequences, the TCA doesn't work, in which case you're no worse off than you are now, or it does and in 6 months you'll be wondering what all the fuss was about.Quote:
Originally Posted by SideFX
"Lose your life" because of tachycardia? Even if the TCA should trigger it tachycardia is not often fatal in the otherwise reasonably healthy and can be controlled fairly easily. Anxiety itself is a risk factor not only for heart disease, but all causes of premature death, some directly, but mostly by encouraging unhealthy behaviors such as sedentary lifestyles, poor diets, drug use, both legal and illegal, etc.Quote:
It really really scares me that I will now lose my life to this terror !!!!
Fwiw, I've been on a very high dose of the TCA dosulepin which is the most cardio toxic AD produced for nearly 30 years. At one time it had about 70% of the UK market, but has since been removed from the British National Formulary and the UK drug regulator has recommended only psychiatrists and other special-care doctors be allowed to prescribe it to new patients. Yet, my nearly 80 yo ticker is unfazed, although I began taking a blood pressure med following a partial lung removal 18 years ago because this places extra pressure on the heart.
At what dose? That it sedated you suggests it was at the sub therapeutic range. Because of the way it works trazodone becomes less sedating as the dose increases and sedation is usually only minor once in the therapeutic range, especially with the slow-release formulation which is better at keeping plasma levels above the sedation threshold. It is usually not effective at doses below 225mg and most need to take at least 300mg to get a response.Quote:
they came back with Trazadone which did nothing, absolutely nothing
...Trazadone did absolutely nothing, not a thing and caused me to fall asleep easy, but wake up every hour. So woke up 7/8 times a night, it was a terrible meditation for me !!
Possibly. If not for your experience with amitriptyline I'd be suggesting doing a cross taper to reduce the risk. Not so much because I think switching to the TCA will cause a repeat physically, but because you're possibly psychologically primed to experience it. An anxious mind can produce our worst nightmares if given half a chance. But the Pdoc will be in a better position to make that call.Quote:
But won't I get even worse with the withdrawal from brintillex ????
That's the usual time frame.Quote:
Can I ask should I still expect a response within 6-12 weeks at a therapeutic dose ????
Your situation is far from hopeless. The main problem seems to have been the medical advice you've been given. Hopefully, this is about to change. Also, have you tried therapy? The cognitive/behavioural (CBT, REBT, etc) and mindfulness therapies can be at least as effective as ADs.Quote:
I've no time for it anymore I've lost all hope PDU !!!
I’ve been through so much CBT I’m sick of it and it had zero effect on my MH it’s what the NHS throw at everyone and for me it’s s definite nope useless. I’m very self aware and well read on meds and their mechanism of action and I’ve heard many a story of people who can’t tolerate SSR’s Yet get on great with TCA’s and I don’t know why. Is this something you could shed light on PDU ???Quote:
Originally Posted by panic_down_under
Which indicates the improvement was more likely from just the normal ebb and flow of these disorders than the meds.Quote:
Originally Posted by SideFX
Apparently so: Brown TC, 1979.Quote:
I have read that imipramine is less cardio toxic than Amatrip?????
I'm one of them. SSRIs make me manic. The TCAs and MAOIs don't. It comes down to how individual biology meshes with the med.Quote:
and I've heard many a story of people who can't tolerate SSRs Yet get on great with TCAs and I don't know why.
Then grab the opportunity with both hands. At my worst I needed to be hospitalised to switch meds. It beats facing the side-effects and increased anxiety and depression on your own at home where the mind has a lot of time to ruminate!Quote:
My Pdoc mention hospitalisation if switching to a TCA, she did seem open to the idea, which did surprise me !!!!
I can’t stand the thought of going back into a physc hospital, I have had 2 experiences and hate the places, they are chaotic in the UK !!!! So this is the path of last resort for me, can you understand how that makes me feel. Albeit I know if I change that’s the safest environment to do so pal !!!!!Quote:
Originally Posted by panic_down_under
Only by trying it, unfortunately. :sad:Quote:
Originally Posted by SideFX
Do NHS general medical hospitals have psychiatric wards? Here most do usually specialising in a particular disorder with a few beds for other indications and they are not much different to the other wards. I've only been a visitor to one of the few psychiatric hospitals and then not to one of the locked wards so can't really comment. My experience has mostly been in veteran's hospitals which were excellent, but most either no longer exist, or have been absorbed into the state hospital systems.Quote:
I can't stand the thought of going back into a physc hospital, I have had 2 experiences and hate the places, they are chaotic in the UK !!!!
Talk to the Pdoc about getting into a non psychiatric hospital for a few weeks, or at least into a ward for the less severe disorders if a psych hospital is the only option.Quote:
So this is the path of last resort for me, can you understand how that makes me feel. Albeit I know if I change that's the safest environment to do so pal !!!!!
Psych wards in the UK are in a separate annex to the main hospital and full of shouting and screaming patients. They are not a quite relaxed environment at all. Plus the staff couldn’t care less if you live or die, they’re completely useless honestly they couldn’t care less and that’s the honest truth !!!! Ta for your insight and suggestions l, all of which are in my logarithm of which direction to take, based on response or non response Ta JohnQuote:
Originally Posted by panic_down_under
Cool. I hope it works out for you, John. :)