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Suggest Treatment For Severe Anxiety
Question: I have depression, severe anxiety, social phobia and severe insomnia. I am on lexapro 30 mgs ( I was on 20 mgs but only getting 4 hours sleep on a good night and still very very anxious and nervy, so my GP increased dose to 30 mgs ) which didn't make any difference except very possibly my anxiety and insomnia is now worse. I also take inderal 40 to 120 mgs for my anxiety ( 240 to 300 mgs makes it possible for me to attend PTA meetings) I begged my GP for sleeping tabs no go so I researched the internet and found trazodone for insomnia, I am now on 75 mgs for the last 4 nights. Slept fantastic first and second night more than 8 hours but the last 2 nights my sleep is reverting back to 4 hours and less. Can you suggest any other drug combination ? I am still taking lexapro as it keeps my depression in check ( attempted suicide 3 times last one ending up in a psych unit for 3 weeks ) probably why my GP is reluctant to prescribe sleeping tabs as I took 1000 Valium tablets @ 10 mgs washed down with 5 cans of lager, the only reason I survived the ear doc reckoned was my high tolerance for Valium having been on them for 10 years previous . I am fast loosing the will to live with not sleeping and xnxiety through the roof. With all the drug combinations there must be something I can try . Sorry I forgot I also have restless leg syndrome. My social phobia/ anxiety is caused my blushing at every occasion. I actually went to London and saw a surgeon who performs ETS surgery but he felt my age could affect the success of this operation and I could still be left with excess sweating etc. he did say he could use Botox on my neck to help alleviate the ugly red rash from nerves but it wold be a temporary fix and I would need it done twice a year.
Brief Answer:
Severe anxiety
Detailed Answer:
Hello
Thanks for asking from Health Care Magic
I have read your query in detail and I can understand your concern. You have severe anxiety mainly related to social situations (social phobia) and insomnia. You are on 30 mg Escitalopram (lexapro), Propranolol 40-120 mg and Trazodon 75 mg per day. There is relief in symptoms of depression but sleep is very less and this is causing significant distress.
I would like to tell you that Escitalopram is a drug of SSRI group and it is a good anti-depressant. It is usually prescribed in morning hours as in most of individuals it causes insomnia (only in some the drug cause somnolence). First thing I would advise you to consult your psychiatrist for change of drug if possible to a drug of same class that causes sedation. Paroxetine (also a SSRI) can be tried, the drug is a good antidepressant with equal efficacy but its side effect of sedation can be used in your problem of insomnia.
Other anti-depressants like Mirtazepine in 7.5 mg dose can also be reserved for poor sleep. The drug help in good sleep and will increase the anti-depressant action of lexapro.
Trazodon is also a good drug for sleep but the drug cause sleep for 2-3 days and you again developed poor sleep. In depression a lot of sleep abnormalities are seen. Reduced REM (a type of sleep) latency and change in sleep rhythm are common findings. Even correcting sleep rhythm results in improvement in sleep and depression. Drugs like Melatonin agonists as Ramelteon corrects the sleep rhythm and helps in proper sleep which ultimately improves depression. The occurrence of restless syndrome (which is also a sleep disorder) is also increasing the possibility of sleep rhythm abnormality in your case. Ramelteon will improve RLS also.
Also I would like to know at what times you are taking Propranolol. The drug should be taken in morning or in afternoon only. Propranolol should be avoided in evening hours.
In last to summarise, In my opinion the reason of insomnia is severe anxiety and the insomnia is resulting in depressive symptoms. A vicious cycle of anxiety, insomnia, depression has developed and we have to break that cycle.
Thanks, hope this helps you.
You can ask again if you have more queries, I will be glad to answer.
Severe anxiety
Detailed Answer:
Hello
Thanks for asking from Health Care Magic
I have read your query in detail and I can understand your concern. You have severe anxiety mainly related to social situations (social phobia) and insomnia. You are on 30 mg Escitalopram (lexapro), Propranolol 40-120 mg and Trazodon 75 mg per day. There is relief in symptoms of depression but sleep is very less and this is causing significant distress.
I would like to tell you that Escitalopram is a drug of SSRI group and it is a good anti-depressant. It is usually prescribed in morning hours as in most of individuals it causes insomnia (only in some the drug cause somnolence). First thing I would advise you to consult your psychiatrist for change of drug if possible to a drug of same class that causes sedation. Paroxetine (also a SSRI) can be tried, the drug is a good antidepressant with equal efficacy but its side effect of sedation can be used in your problem of insomnia.
Other anti-depressants like Mirtazepine in 7.5 mg dose can also be reserved for poor sleep. The drug help in good sleep and will increase the anti-depressant action of lexapro.
Trazodon is also a good drug for sleep but the drug cause sleep for 2-3 days and you again developed poor sleep. In depression a lot of sleep abnormalities are seen. Reduced REM (a type of sleep) latency and change in sleep rhythm are common findings. Even correcting sleep rhythm results in improvement in sleep and depression. Drugs like Melatonin agonists as Ramelteon corrects the sleep rhythm and helps in proper sleep which ultimately improves depression. The occurrence of restless syndrome (which is also a sleep disorder) is also increasing the possibility of sleep rhythm abnormality in your case. Ramelteon will improve RLS also.
Also I would like to know at what times you are taking Propranolol. The drug should be taken in morning or in afternoon only. Propranolol should be avoided in evening hours.
In last to summarise, In my opinion the reason of insomnia is severe anxiety and the insomnia is resulting in depressive symptoms. A vicious cycle of anxiety, insomnia, depression has developed and we have to break that cycle.
Thanks, hope this helps you.
You can ask again if you have more queries, I will be glad to answer.
Above answer was peer-reviewed by :
Dr. Vinay Bhardwaj
Thank you for answering me so quickly Dr Bishnoi,
I take 40 mgs of inderal in the am along with 30 mgs of lexapro, usually between 8 and 9 am. I would then take 40 to 60 mgs of inderal in the afternoon, approx 2 to 3 pm and I have often taken 40 to 60 mgs at night hoping to get some sleep as I was prescribed propanol for insomnia while on holiday once in England, so I obviously assumed it aids sleep ?? Do you think paroxetine is a better anti depressant for me ? Would you recommend then taking paroxetine and mirtazepine together ? I really would like to get off inderal because it leaves me exhausted with a horrible heavy feeling like someone is sitting on my neck. Do you have any opinion on the trazodone ? Should I continue on for another week or resign to the fact that it isn't going to work for me ? I seem to have a very high tolerance for drugs of any description. Thank you in advance XXXXXXX
I take 40 mgs of inderal in the am along with 30 mgs of lexapro, usually between 8 and 9 am. I would then take 40 to 60 mgs of inderal in the afternoon, approx 2 to 3 pm and I have often taken 40 to 60 mgs at night hoping to get some sleep as I was prescribed propanol for insomnia while on holiday once in England, so I obviously assumed it aids sleep ?? Do you think paroxetine is a better anti depressant for me ? Would you recommend then taking paroxetine and mirtazepine together ? I really would like to get off inderal because it leaves me exhausted with a horrible heavy feeling like someone is sitting on my neck. Do you have any opinion on the trazodone ? Should I continue on for another week or resign to the fact that it isn't going to work for me ? I seem to have a very high tolerance for drugs of any description. Thank you in advance XXXXXXX
Brief Answer:
Propranol should be avoided in night
Detailed Answer:
Hello again
Propranolol (Inderal) should be avoided in night. The drug cause insomnia and will potentiate your problem of insomnia. Propranolol is used in anxiety because it decreases autonomic symptoms like palpitations, sweating, tremors. It don't aid in sleep. Best thing is to start avoiding the evening dose.
Yes Paroxetine will be better because in terms of efficacy its almost similar to Escitalopram but it causes sedation which can prove beneficial in your case. Secondly use of this drug will ameliorate the need of very high dose of escitalopram (which you are taking).
If your doctor agrees to prescribe Paroxetine then there is no need for Mirtazepine because you are already taking trazodon (one more antidepressant). Combination is used in resistant depression cases.
Trazodon is a good drug. As per my opinion you should take the drug for at least some more weeks (or till you consult your psychiatrist), because the drug takes time to show its full effect. The drug cause immediate sedation but it is also a good anti-depressant. Its antidepressant action will aid in sleep.
Don't change medicine so frequently, and please don't overmedicate yourself. You will be alright in some time.
Thanks, hope this helps you.
You can ask again if you have more doubts.
Take care
Propranol should be avoided in night
Detailed Answer:
Hello again
Propranolol (Inderal) should be avoided in night. The drug cause insomnia and will potentiate your problem of insomnia. Propranolol is used in anxiety because it decreases autonomic symptoms like palpitations, sweating, tremors. It don't aid in sleep. Best thing is to start avoiding the evening dose.
Yes Paroxetine will be better because in terms of efficacy its almost similar to Escitalopram but it causes sedation which can prove beneficial in your case. Secondly use of this drug will ameliorate the need of very high dose of escitalopram (which you are taking).
If your doctor agrees to prescribe Paroxetine then there is no need for Mirtazepine because you are already taking trazodon (one more antidepressant). Combination is used in resistant depression cases.
Trazodon is a good drug. As per my opinion you should take the drug for at least some more weeks (or till you consult your psychiatrist), because the drug takes time to show its full effect. The drug cause immediate sedation but it is also a good anti-depressant. Its antidepressant action will aid in sleep.
Don't change medicine so frequently, and please don't overmedicate yourself. You will be alright in some time.
Thanks, hope this helps you.
You can ask again if you have more doubts.
Take care
Above answer was peer-reviewed by :
Dr. Vinay Bhardwaj
Thank you for your reply Doctor Bishnoi,
I have googled mirtazepine, and it is zispin ( yes I know you know this !! I didn't ) I was on this a few years ago and I had to stop taking it, I would get ravenously hungry when I took it, and eat chocolate, I put on a ridiculous amount of weight in a very short time. Yes you could say don't eat chocolate but I found it near impossible not to give in to the craving. Is there any drug similar to zispin you could recommend ? Yes I will continue on with the trazodone for a few more weeks as I did read many good reviews about this drug for insomnia but if it still doesn't work after another few weeks I will ask my GP about a drug similar to zispin that you recommend. My GP is not familiar with psych drugs and to see a pyschiatrist on a medical card ( free ) can take up to 6 to 10 months in XXXXXXX in non emergency cases. Also what dose paroxetine should I start on ? Yes I am very aware of discontinuation syndrome after coming off seroxat cold turkey 10 years ago, it was torture. My GP just kept telling me it was depression that was causing my symptoms even though I was so weak I couldn't even hold a cup of tea. It took 6 months for symptoms to disappear, and yes I changed my GP !!
So to recap two questions, what starting dose of paroxetine ?
And what drug can I try instead of zispin ?
Thank you XXXXXXX
I have googled mirtazepine, and it is zispin ( yes I know you know this !! I didn't ) I was on this a few years ago and I had to stop taking it, I would get ravenously hungry when I took it, and eat chocolate, I put on a ridiculous amount of weight in a very short time. Yes you could say don't eat chocolate but I found it near impossible not to give in to the craving. Is there any drug similar to zispin you could recommend ? Yes I will continue on with the trazodone for a few more weeks as I did read many good reviews about this drug for insomnia but if it still doesn't work after another few weeks I will ask my GP about a drug similar to zispin that you recommend. My GP is not familiar with psych drugs and to see a pyschiatrist on a medical card ( free ) can take up to 6 to 10 months in XXXXXXX in non emergency cases. Also what dose paroxetine should I start on ? Yes I am very aware of discontinuation syndrome after coming off seroxat cold turkey 10 years ago, it was torture. My GP just kept telling me it was depression that was causing my symptoms even though I was so weak I couldn't even hold a cup of tea. It took 6 months for symptoms to disappear, and yes I changed my GP !!
So to recap two questions, what starting dose of paroxetine ?
And what drug can I try instead of zispin ?
Thank you XXXXXXX
Brief Answer:
Mirtazepine
Detailed Answer:
Hello again
Yes, mirtazepine is known to cause increase in appetite and it can cause significant weight gain, but I have recommended you to consult about 7.5 mg doses. The dose in low and at this dose it will probably not cause craving for foods.
Don't discontinue Trazodon for now and wait for its effects. You will surely improve.
Now to your questions-
- Paroxetine is prescribed with starting dose of 10-12.5 mg. It is available in controlled release preparation (CR 12.5/25 mg). This dose will result in better sleep and with time doses can be increased to 25 or 37.5 mg range. As you are on high dose Escitalopram so Paroxetine should be started with 25-37.5 mg. At this dose withdrawal effects of escitalopram will be minimal.
- If you start paroxetine there is no need to start Mirtazepine as for now. You are already on Trazodon which is also an antidepressant.
Please discuss about these with your treating doctor before you make any changes in your prescription.
Thanks, hope this helps you.
You can ask again if you have more questions.
Wish you a good health.
Mirtazepine
Detailed Answer:
Hello again
Yes, mirtazepine is known to cause increase in appetite and it can cause significant weight gain, but I have recommended you to consult about 7.5 mg doses. The dose in low and at this dose it will probably not cause craving for foods.
Don't discontinue Trazodon for now and wait for its effects. You will surely improve.
Now to your questions-
- Paroxetine is prescribed with starting dose of 10-12.5 mg. It is available in controlled release preparation (CR 12.5/25 mg). This dose will result in better sleep and with time doses can be increased to 25 or 37.5 mg range. As you are on high dose Escitalopram so Paroxetine should be started with 25-37.5 mg. At this dose withdrawal effects of escitalopram will be minimal.
- If you start paroxetine there is no need to start Mirtazepine as for now. You are already on Trazodon which is also an antidepressant.
Please discuss about these with your treating doctor before you make any changes in your prescription.
Thanks, hope this helps you.
You can ask again if you have more questions.
Wish you a good health.
Note: For further guidance on mental health, Click here.
Above answer was peer-reviewed by :
Dr. Shanthi.E
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