Imipramine, have I made the right choice?

[panic_down_under]

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.

[Dazzlar13]

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]

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.

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.

[Dazzlar13]

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..

[panic_down_under]

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.

[Dazzlar13]

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]

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.

[Dazzlar13]

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]

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.

[Dazzlar13]

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.