Up and Down...why?

[Utah49er]

However, within a few weeks the brain should respond by decreasing serotonin synthesis and expression causing anxiety levels to drop back to around baseline until the med kicks-in.

Ok, although it felt like on my six weeks of Lexapro it never went down to baseline...maybe it did but my baseline was really high. I never stopped waking early in a panic during the six weeks on Lexapro...and that sucked!

If there is no significant improvement after 8-10 weeks at a particular dose.

So would you stay at 10mgs for 8-10 weeks, then 20 for 8-10 weeks, then 30..etc? That seems like a long trial if it isn't working. Since you think (and I tend to agree as playing with lower doses have done little for me this time) I will need a higher dose, should I move through the doses a little quicker? I am currently on day 7 at 10mgs and still on the 300mgs x2 of Pregabalin. I Take them at about 11 and 11. I do think the Pregablin helps me to sleep better during the Paxil startup, and I am mentally handling the anxiety increase this time, but it is still strong (even on the Pregabalin).

---------- Post added at 09:55 ---------- Previous post was at 09:53 ----------

Hi Utah49er - I can understand what you say about work being stressful but a distraction at the same time. I was in teaching, and I'd get very stressed in anticipation of a class, but then mostly once I got in the classroom I was fine. (Unfortunately, I started getting panic surges while teaching, but with the meds that stopped and the pre-class stress came down to a bearable level).

I hope you're travelling okay this week.

Thanks Hanshan! Another week, another really tough grind through anxiety. Man I hope I start coming out the other side of this soon.

[panic_down_under]

So would you stay at 10mgs for 8-10 weeks, then 20 for 8-10 weeks, then 30..etc?

Not at 10mg because that is a sub therapeutic starter dose. It should been increased to 20mg after 7 days. But I would give 20mg more time.

Since you think (and I tend to agree as playing with lower doses have done little for me this time) I will need a higher dose, should I move through the doses a little quicker?

I suspect you will need more than 20mg, but there is no way of really knowing. You could go up to 30mg and then 40mg after a few weeks if you wish.

[Utah49er]

Not at 10mg because that is a sub therapeutic starter dose. It should been increased to 20mg after 7 days. But I would give 20mg more time.

Sounds good, thanks for your advice! I will be starting 20mgs tomorrow...and then my clock starts counting towards recovery...correct? Does the clock reset if I up the dose?

Also, I was just wondering, from your posts to me, you seem to view Mirtazapine as little more than a sleep aid or anti-histamine. From the clinical trials I have read, it was found to be at least as effective as many older anti-depressants (especially for agitated depression with insomnia). You are obviously more knowledgeable than me at these things, and was wondering your opinion on Mirtazapine.

[panic_down_under]

I will be starting 20mgs tomorrow...and then my clock starts counting towards recovery...correct? Does the clock reset if I up the dose?

Yes, and no. However, there may be a temporary increase in side-effects after dose increases, although they are usually not as severe as at the beginning.

from your posts to me, you seem to view Mirtazapine as little more than a sleep aid or anti-histamine.

Yes, because this is all it is. It is about 1,000 times more effective at blocking the histamine HI receptor than any other. It is not a classic antidepressant, neither significantly inhibiting neurotransmitter reuptake, or promoting neurogenesis.

I have read, it was found to be at least as effective as many older anti-depressants (especially for agitated depression with insomnia).

Yes, it can be effective for both because of its sedative effects, particularly at lower doses. It can, however, become agitating at the upper end of the dose range.

was wondering your opinion on Mirtazapine.

I think it can be a better longer term option than benzodiazepines as a sedative for anxiety, as a sleep aid (but when available trazodone is better, imho) and it may speed up SSRI kick-in a little.

But I'm not a fan because it also has some potential serious long-term side-effects such as diabetes due to the large weight-gains it often causes by stimulating carbohydrate cravings, and there is also a risk of liver injury with about 10% of those taking the drug showing liver abnormalities, although usually these are not significant. However, a small number may develop blood dyscrasias (PDF) which is the medical term for a wide range of blood abnormalities such as the white blood cell disorders neutropenia and agranulocytosis. While rare, these should be watched for. Typical symptoms are fever, sore throats and other signs of infection.

Mirtazapine is derived from the older antidepressant mianserin which was initially popular, particularly in Europe until doctors realised it was slightly less effective than an equivalent dose of M&Ms. So the makers rejigged the chemistry a little to create mirtazapine which they claimed was a much more potent alpha 2-adrenoceptor (a2) and serotonin 5-HT2a receptor antagonist. Both claims are untrue. The mianserin a2 binding potential is between 23-73 *Ki, that of mirtazapine 58-141 Ki. For 5-HT2a the binding potentials are mianserin: 0.36-7.0 Ki, mirtazapine 2.0-17 Ki. Mirtazapine remains popular while mianserin is rarely prescribed these days because the makers spend a lot of money marketing the drug to doctors.

* The Ki value is based on the amount of the drug needed to occupy 50% of the target receptors, so the lower the Ki the more potent the med.

[hanshan]

Hi Utah49er - Take care with my compatriot, Panic_Down_Under, as he quotes a lot of science, but does so selectively.

For example, he says: "there is also a risk of liver injury with about 10% of those taking the drug showing liver abnormalities, although usually these are not significant".

The actual quote reads: "Liver test abnormalities have been reported to occur in up to 10% of patients on mirtazapine, but elevations are usually modest and rarely require dose modification or discontinuation".

There is a big difference between a liver abnormality and a liver test abnormality, particularly when "elevations are usually modest and rarely require dose modification or discontinuation". Most blood tests show transient small elevations or decreases in one or two measurements that aren't of major significance.

While researching information online is admirable, with the greatest respect I feel that Panic_Down_Under favours the drugs of thirty or forty years ago (MAOIs and TCAs, followed by SSRIs), and uses his quotes to support his pre-existing beliefs. However, for example, the toxicity and side-effect profile of mirtazapine is nothing compared to MAOIs and TCAs, which can be downright dangerous to deadly in overdose, one reason that they are sparingly prescribed today.

As for the neurotransmitter action of mirtazapine, it boosts serotonin and noradrenaline activity through non-classic, novel means. Neurotransmitter re-uptake inhibition is only one mechanism for increasing neurotransmitter activity - that's what makes mirtazapine's novel activity a good alternative to classic SSRIs (selective serotonin re-uptake inhibitors).

Utah49er, do ask for advice and support, but we are not doctors or qualified medical staff on this website, and shouldn't try to fill that role. Certainly there is a little bit of knowledge, but mostly the support comes from people who have taken these meds and faced similar problems.

[Utah49er]

Utah49er, do ask for advice and support, but we are not doctors or qualified medical staff on this website, and shouldn't try to fill that role. Certainly there is a little bit of knowledge, but mostly the support comes from people who have taken these meds and faced similar problems.

Yes I understand, and have been very grateful for the support and advice. As I said, I was scared of another SSRI trial and was hoping to try Mirtazapine as it seemed much less painful to start-up. Alas, that didn't happen and I am doing my Paxil startup now. It has gone ok, I have felt some increase in anxiety, but I have been managing. Just started on 20mgs today after 8 days on 10mgs. I was just asking Panic's opinion on Mirt, as he has insinuated he didn't think much of it as a primary AD for anxiety, but you and others have had great success. I have to think at some point and SSRI will kick in and work as Zoloft was effective, even at its lowest dose for 8 years, and it would make no sense I couldn't get back to that with an SSRI again after just a 4 month break from them.

[Utah49er]

I am now one week on a full 20MG dose of Paxil to go with my 600mgs of pregabalin...I feel awful! I woke up in a panic at 5:30AM (something I did a lot during my trial of Lexapro). I know I need to be patient, but it is hard to have faith as Lexapro never kicked in after 6 weeks on therapeutic dose. I need something to work, I just want to get back to my life! The pregabalin helped, but it seems like it is now just being overpowered by the startup effects of Paxil. I just don't get why after a short 4 month break from Zoloft, SSRIs now increase my anxiety so much. I am sure I need to just be patient, but this is REALLY hard. Any advice?

[hanshan]

Hi Utah49er - It is horrible when you are hoping so much for something to work. Hopefully it is just a blip. Many will attest that starting up can actually increase anxiety, but then have a beneficial effect.

Maybe you went up to 20 mg too quickly? The usual approach for anxiety is "start low, go slow".

Good luck, and I hope you are feeling better.

[PixieP]

I wish I could offer advice but right now I'm not best qualified to do that! What I can offer is a listening ear if you want to vent. The best people to vent to are those who truly understand what you're going through and how all consuming anxiety can feel.
If it makes you feel any better (and not so alone), I had a horrific day on Monday, drove the 30 miles back from work literally sobbing the whole way (feeling like I would never get better) and ended up at the GP surgery crying on a lovely receptionist who arranged for me to speak to the emergency doctor. I now have a small supply of lorazepam to take the edge off things when I really can't cope.
I've since spoken to my own doctor and am now weaning off mirtazapine and will be switching back to venlafaxine (on the advice of the psych) to augment the pregabalin. I'm not holding out much hope though as ven did nothing for me when I went back on it before. Still, at least with the aid of lorazepam I've had a few slightly calmer days.
So the upshot is it looks like there's not gonna be a quick fix for either of us but at least there's always plenty of support on here.Has your doc ever given you any benzos for short term relief? GPs in the UK normally prescribe diazepam (valium) but even 10mg doesn't touch my anxiety hence the lorazepam (same effect, slightly different action and duration of effect).
I truly hope the meds kick in soon for you. Hopefully soon you will be able to look back and this will all seem like a bad dream,

[PixieP]

Hi Utah
How are you getting on now? Hope the meds have started to kick in now?