Mirtazapine No Longer Working

[LisaCM]

Hi, this is my first post.
I have had GAD for over 16 years and in between times was managing it fairly well with Mirtazapine.
I came off it for a long time and then had to go back on it just over 2 years ago just after my daughter was diagnosed with Autism.
In the past year I have become progressively worse to the point where I was having to have wine to go shopping or do anything outside the house. The GPs answer was, just go for a coffee or an exercise class with friends and it will pass. I have tried so hard, walking miles, eating better the lot and still I got worse.
I started having severe panic attacks around autumn and was really bad over Christmas to the point where I hardly leave the house now and am almost always feeling on edge and anxious.
I've had two short courses of Diazepam 2mg which I use very sparingly but is due to run out.
CPN coming to see me for assessment on Tuesday. Not sure what the next step will be. I've tried almost every AD and cannot tolerate SSRIs - I recall after only one Lustral tablet that I was really agitated. I don't know what they will suggest.
I do my own CBT stuff and mindfulness meditation too. I'm quite scared. I have two young children and feel awful that I feel this way, looking for some hope.

[panic_down_under]

Hi, this is my first post.

Welcome to No More Panic

In the past year I have become progressively worse to the point where I was having to have wine to go shopping or do anything outside the house. The GPs answer was, just go for a coffee or an exercise class with friends and it will pass.

Mirtazapine is a 3rd tier antidepressant, imho. It mainly only acts as an antihistamine, can trigger severe carbohydrate cravings and is by far the most poop-out prone med, often quitting in only a few months.

I've tried almost every AD and cannot tolerate SSRIs - I recall after only one Lustral tablet that I was really agitated.

I can't tolerate SSRIs either for the same reason. What antidepressants have you tried and what was the maximum dose you took? In particular, have you been on any of the older tricyclic antidepressant such as clomipramine (Anafranil), imipramine (Tofranil), desipramine (Norpramin), etc?

I do my own CBT stuff and mindfulness meditation too.

Have you done a course with a therapist? If not, it might be worth doing to learn techniques tailored to your specific issues. I understand most NHS trusts offer it.

[LisaCM]

Hi Panic Down Under,

Thanks for your reply, I really appreciate it.
I have been on afew tricyclics in the past which had a limited effect and then stopped working. It was after trying loads that they gave up and referred me to the psychiatrist afew years ago and she put me on Mirtazapine. They put me back on it briefly after my daughter was born and then I stopped it.
Just been referred back to psych and CPN coming Tuesday.
CBT didn't work before and the psychologist was pretty unhelpful (one day he sat smirking at me and shaking his head saying, "I just don't understand why you're so frightened of the world" - what a thing to say!). What did work was 2 years of Art Psychotherapy which was a pilot in this area and then lost its funding.
What I've heard they do now is send you to a physiotherapist to learn breathing exercises and basic coping strategies which I already do - up until a year ago, I worked as a Hypnotherapist and saw many people who were on endless waiting lists for this.
I am hoping there is something else more substantial that they might suggest a bit like the psychotherapy I had.
I just can't believe this has happened again.
I also wonder what else can be tried medication wise.

[panic_down_under]

I have been on afew tricyclics in the past which had a limited effect and then stopped working.

I wonder if the doses were high enough. Some of us, e.g. me, need doses near the maximum, sometimes even higher, to get a good outcome. I needed to take 300-350mg of imipramine (Tofranil) to bring my PD+agoraphobia under control and have now been on 225mg dosulepin (Dothep) for about 20 years. At 200mg I still experience occasional panic attacks. Both those doses are well above the recommended maximums.

I'd be asking for clomipramine (Anafranil). Although mainly used for OCD, it is the most potent antidepressant currently available, producing strong inhibition of both serotonin and noradrenaline, aka norepinephrine reuptake. Imipramine would be my second choice. For several decades it was the 'gold standard' panic disorder drug until replaced by SSRIs, not because they are more effective, arguably they are less so, but because that are safer in overdose.

[hanshan]

I find pregabalin works well for GAD anxiety. It's probably less helpful for panic attacks, but GAD and panic attacks can occur together. Pregabalin is a lot more subtle if you are used to the rapid anti-anxiety effect of benzodiazepines, but it can be taken long-term.

[SmilingAlbert]

+1 Hanshan. Pregabalin is now officially a treatment in UK (well England certainly, not sure about Scotland) for GAD when other meds have failed.

It is also very good for people like you who can't tolerate SSRIs, as its side effects at the start and ongoing are generally very mild.

As a relatively new drug, not all doctors know about it, and its cost can be an issue - though generics are now available which has helped here. Reviews of it on drugs.com are generally positive (NB it is 'off label' for GAD in the USA, though widely used it would seem)

Worth discussing with your doctor.

Albert