Mirtazapine, diazepam and propranolol concurrent use

[PWO_Nathan]

Hi all.

I hope you're all well.

I am on 30MG mirt since 2013, 2mg Diazepam and I've just been prescribed 40MG propranolol.

I am concerned my medication is continuing to grow and looking for any experiences of anyone taking all 3 at the same time?

Apparently its safe and I have *some* trust in my Dr but I'm genuinely worried about introducing another medicine into my system. More so one that changes heart function / rate..

Tia.

[panic_down_under]

I am on 30MG mirt since 2013, 2mg Diazepam and I've just been prescribed 40MG propranolol.

I am concerned my medication is continuing to grow and looking for any experiences of anyone taking all 3 at the same time?

So the propranolol is being added because the mirtazapine and diazepam are no longer adequately controlling your anxiety disorder, Nathan? Was any thought given to increasing the mirtazapine dose instead of adding the propranolol?

What is your diagnosis, how long have you had it and was mirtazapine the first AD you were prescribed, or have you been on others before it? If so what have you previously taken, at what maximum dose and why was it discontinued?

Apparently its safe and I have *some* trust in my Dr but I'm genuinely worried about introducing another medicine into my system. More so one that changes heart function / rate..

It's safe in it is unlikely to do you any physical harm, but whether what you're taking is the best option is another matter. Imho, poly-pharmacy, the throwing of more and more meds into the mix in the hope of striking some magic combination that solves all problems is a growing curse. If a med is not doing what it is being taken for then what is the point of continuing to take it? Plus, one of the meds you're on is probably undoing whatever good the other might be doing.

[PWO_Nathan]

Thank you for the prompt reply Panic

So I am ex-forces and suffer from PTSD, Agoraphobia and Anxiety.

The Agoraphobia is a 'new' condition only apparently in the last 6 months or so, I generally suffered from HA surrounding my heart and ALS. After various tests to rule out a heart condition (despite me running 10k, never smoking and been physically active) I transitioned onto various other terminal illnesses.

I have always worked and this kept my mind active but in April last year, I lost my job due to the pandemic. Been in lockdown and isolation aggravated my condition and that's when the diazepam was introduced as the Mirtazapine was having seldom impact. I reduced both caffeine and alcohol consumption (twice a week alcohol) before going completely t-total for a few weeks but this didn't appear to impact my anxiety levels.

Recently, I have struggled massively with agoraphobia but it is extremely difficult to manage as there isn't a fix. By this I mean, with my HA I would be 'OK' after a safety behaviour or hour or two.. with this agoraphobia, I cannot leave the house without been in panic but then conversely, sometimes feel I need to 'escape' the house and get out. I do not think I need to go to Hospital or anywhere in particular, I just need to 'get out'.

The Drs are all locums at my surgery and the direction my meds take are entirely contingent on who I speak to. The Dr last week made the most sense when he said to change the mirt as this is for depression more than anxiety and he suggested I take multiple 2mg diazepam at once when needed as the low dose is not effective. I spoke with a different Dr yesterday who seemed to be of the same opinion as you and didnt feel I should be on diazepam full stop. However he said to take it as short term while also taking 40mg propranolol but I am concerned at taking a new med that messes with my heart. Also concerned, like you have mentioned, that perpetually increasing meds isnt the answer...

Finally, re increasing the mert, apparently going up in doses reduces the effectiveness of mert which I thought was odd but I am not qualified to disagree. I tried Sertaline previously but this gave me ectopic beats for a full day after I took it.

[panic_down_under]

So I am ex-forces and suffer from PTSD, Agoraphobia and Anxiety.

Okay, before we get into the specifics a short explanation of how ADs work and then I'm slightly rearranging the order of your post, Nathan.

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 more detailed explanations see: Depression and the Birth and Death of Brain Cells (PDF) and How antidepressant drugs act.

Finally, re increasing the mert, apparently going up in doses reduces the effectiveness of mert which I thought was odd but I am not qualified to disagree.

This is because mirtazapine isn't really an antidepressant despite what is claimed on the tin. It has virtually nil effect on serotonin, or noradrenaline, aka norepinephrine, reuptake and if there is any evidence that it stimulates hippocampal neurogenesis I haven't been able to find it. It is really only a very sedating antihistamine and the positive response mostly comes from essentially sedating the anxiety. However, one of the stranger things about antihistamines is the sedation decreases as the dose increases although the maximum 45mg is often still a little more effective than 30mg.

I reduced both caffeine and alcohol consumption (twice a week alcohol) before going completely t-total for a few weeks but this didn't appear to impact my anxiety levels.

A wise move as caffeine, and especially alcohol generally worsen anxiety. Caffeine often triggers anxiety by mimicking the physical flight-or-fight symptoms of anxiety. Despite being the most (self)prescribed anti anxiety/depression med consumed alcohol has an even more insidious effect, it causes the same atrophy of the hippocampi as stress hormones do in part by deranging stress hormone production. However, much of the damage is probably more direct. Even moderate drinking can result in significant hippocampal atrophy (study: Topiwala A, 2017; - see also: Anderson ML, 2012; Morris SA, 2010; Crews FT, 2003).

I have always worked and this kept my mind active but in April last year, I lost my job due to the pandemic. Been in lockdown and isolation aggravated my condition

Sadly, an all too common response in these 'interesting' times.

and that's when the diazepam was introduced as the Mirtazapine was having seldom impact.

Unfortunately, the benzodiazepines have the same effect on the brain as alcohol and stress hormones do, i.e. they inhibit hippocampal neurogenesis and block ADs from reversing the damage, see: Boldrini M, 2014; Nochi R, 2013; Sun Y, 2013;
Song J, 2012; Wu X, 2009; Stefovska VG, 2008).

In light of these studies benzodiazepines should only be used for a couple of weeks when first taking antidepressants to ease the common initial increase in anxiety levels, for a while after AD dose increases for the same reason and thereafter for occasional breakthrough anxiety. If an antidepressant isn't adequately controlling anxiety on its own even at the maximum recommended or tolerated dose then switching to another which might be more effective should be considered ahead of supplementing it with a benzodiazepine. See also: the 'Ugly' part of Benzodiazepines: The Good, The Bad, and the Ugly.

The Agoraphobia is a 'new' condition only apparently in the last 6 months or so, I generally suffered from HA surrounding my heart and ALS. After various tests to rule out a heart condition (despite me running 10k, never smoking and been physically active) I transitioned onto various other terminal illnesses.

...I have struggled massively with agoraphobia but it is extremely difficult to manage as there isn't a fix. By this I mean, with my HA I would be 'OK' after a safety behaviour or hour or two.. with this agoraphobia, I cannot leave the house without been in panic but then conversely, sometimes feel I need to 'escape' the house and get out. I do not think I need to go to Hospital or anywhere in particular, I just need to 'get out'.

Been there, got the t-shirt, mate. There have been times, fortunately now long ago, when I couldn't walk outside the front door to get the post. There are no easy fixes, but in most cases there is a fix. It is just going to take time and maybe some trial and error to find the best med, singular hopefully, fit for your biology. You should also talk to your doctor/s about therapy. The cognitive/behavioural/mindfulness therapies can be very effective. They actually work by the same neurogenesis process as ADs.

I tried Sertaline previously but this gave me ectopic beats for a full day after I took it.

So you then stopped taking it? Also, what was the starting dose?

[gronk]

This is really interesting stuff thanks bro