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Thread: Imipramine, have I made the right choice?

  1. #1
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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.

  2. #2
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    Re: Imipramine, have I made the right choice?

    Quote Originally Posted by Dazzlar13 View Post
    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.
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  3. #3
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    Re: Imipramine, have I made the right choice?

    Quote Originally Posted by panic_down_under View Post
    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 View Post
    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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    The opinions expressed above are based on my observations and, where applicable, interpretation of cited data and are general in nature. Consult your physician before acting on anything stated.

  6. #6
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    Re: Imipramine, have I made the right choice?

    Quote Originally Posted by pulisa View Post
    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.

  8. #8
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    Re: Imipramine, have I made the right choice?

    Quote Originally Posted by panic_down_under View Post
    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 :-(

  9. #9
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    Re: Imipramine, have I made the right choice?

    Quote Originally Posted by pulisa View Post
    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.

  10. #10
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    Re: Imipramine, have I made the right choice?

    Quote Originally Posted by Dazzlar13 View Post
    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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    The opinions expressed above are based on my observations and, where applicable, interpretation of cited data and are general in nature. Consult your physician before acting on anything stated.

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