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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.
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Re: Imipramine, have I made the right choice?
Quote:
Originally Posted by
Dazzlar13
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.
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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.
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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.
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Re: Imipramine, have I made the right choice?
Quote:
Originally Posted by
panic_down_under
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.
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Re: Imipramine, have I made the right choice?
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.
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Re: Imipramine, have I made the right choice?
Quote:
Originally Posted by
Dazzlar13
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:
"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. See also:
A systematic review of the serotonergic effects of mirtazapine in humans...
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
Moreover, as Ian Whyte points out, mirtazapine is a serotonin 5-HT2a receptor antagonist. They can block the body temperature spike which does the damage in SS/ST although in humans the recommended treatments are the more potent 5-HT2a antagonists cyproheptadine and chlorpromazine.
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Re: Imipramine, have I made the right choice?
Quote:
Originally Posted by
pulisa
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.
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Re: Imipramine, have I made the right choice?
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.
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Re: Imipramine, have I made the right choice?
Quote:
Originally Posted by
panic_down_under
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:
"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. See also:
A systematic review of the serotonergic effects of mirtazapine in humans...
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
Moreover, as Ian Whyte points out, mirtazapine is a serotonin 5-HT2a receptor antagonist. They
can block the body temperature spike which does the damage in SS/ST although in humans the
recommended treatments 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 :-(
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Re: Imipramine, have I made the right choice?
Quote:
Originally Posted by
pulisa
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.
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Re: Imipramine, have I made the right choice?
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Originally Posted by
Dazzlar13
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 for surgery. If it isn't helping you sleep then mirtazapine is unlikely to do so.
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Re: Imipramine, have I made the right choice?
Quote:
Originally Posted by
panic_down_under
And you still can't sleep? In the U.S. promazine is only registered as a veterinary drug often used to
tranquilize horses 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?
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Re: Imipramine, have I made the right choice?
Quote:
Originally Posted by
Dazzlar13
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.
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Re: Imipramine, have I made the right choice?
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.
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Re: Imipramine, have I made the right choice?
Quote:
Originally Posted by
Dazzlar13
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.
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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.
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Re: Imipramine, have I made the right choice?
Quote:
Originally Posted by
panic_down_under
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.
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Re: Imipramine, have I made the right choice?
Quote:
Originally Posted by
Dazzlar13
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.
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Re: Imipramine, have I made the right choice?
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.
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Re: Imipramine, have I made the right choice?
Quote:
Originally Posted by
Sleepy
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.
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Re: Imipramine, have I made the right choice?
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?
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Re: Imipramine, have I made the right choice?
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Originally Posted by
Belleblue
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.
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[/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 to think this (see also).
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Re: Imipramine, have I made the right choice?
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! :)
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Re: Imipramine, have I made the right choice?
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.
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Re: Imipramine, have I made the right choice?
Quote:
Originally Posted by
Dazzlar13
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.
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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.
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Re: Imipramine, have I made the right choice?
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.
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Re: Imipramine, have I made the right choice?
Quote:
Originally Posted by
Dazzlar13
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.
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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.
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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 (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) and How antidepressant drugs act.
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Re: Imipramine, have I made the right choice?
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..
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Re: Imipramine, have I made the right choice?
Quote:
Originally Posted by
Dazzlar13
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). 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.
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should I ask for a second opinion?
Definitely
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Re: Imipramine, have I made the right choice?
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Originally Posted by
panic_down_under
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). 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.
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Re: Imipramine, have I made the right choice?
Quote:
Originally Posted by
Dazzlar13
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:
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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.
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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 to minimise it and Biotene 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.
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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 useful.
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Re: Imipramine, have I made the right choice?
Quote:
Originally Posted by
panic_down_under
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 to minimise it and
Biotene 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 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.
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Re: Imipramine, have I made the right choice?
Quote:
Originally Posted by
Dazzlar13
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.
Quote:
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.
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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.
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Re: Imipramine, have I made the right choice?
Quote:
Originally Posted by
panic_down_under
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.
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Re: Imipramine, have I made the right choice?
Quote:
Originally Posted by
Dazzlar13
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, 2003 found the NTT for MAOIs = 2.9, TCAs = 4.3, SSRIs = 5.1.
Arroll B, 2005 came up with a similar result: TCAs = 4, SSRIs = 6.
Quote:
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.
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Re: Imipramine, have I made the right choice?
Quote:
Originally Posted by
panic_down_under
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, 2003 found the NTT for MAOIs = 2.9, TCAs = 4.3, SSRIs = 5.1.
Arroll B, 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..
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Re: Imipramine, have I made the right choice?
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Originally Posted by
Dazzlar13
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.
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Re: Imipramine, have I made the right choice?
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Originally Posted by
panic_down_under
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?
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Re: Imipramine, have I made the right choice?
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Originally Posted by
Dazzlar13
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.
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Re: Imipramine, have I made the right choice?
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.
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Re: Imipramine, have I made the right choice?
Quote:
Originally Posted by
Dazzlar13
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.
Quote:
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.
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Re: Imipramine, have I made the right choice?
Quote:
Originally Posted by
panic_down_under
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.