Brief Answer:
Go slow while tapering off further. You need to continue antidepressant.

Detailed Answer:
Hi,

Welcome back!

First of all, congratulations on having reduced your intake from 300 mg to 100 mg per day over just a couple of weeks. You have done very well.

From what you have mentioned, it appears that you went through a very bad time after your brother's demise and took recourse to zolpidem in order to cope. I guess that in addition to insomnia, you also might have had persistent low mood, loss of interest, decreased concentration, fatigue, poor appetite and hopelessness during this period. You also probably were feeling guilty about not having been able to save your brother. All these are common in people who suffer from bereavement but when severe, these can also be symptoms of a depressive episode. Your doctors probably thought so and therefore started you on antidepressants (fluoxetine, mirtaz). If so, then your sleep problems would have been secondary to depression and just taking sleep inducing medicines in usual dosages would not have given you good results.

You have mentioned that you are not doing well at the office. I assume that you still are having low mood and poor concentration, which is creating problems at the work place. I would suggest that as prescribed by your doctor, you continue with an antidepressant so that the basic problem can be resolved. Usually antidepressants take a few weeks for response. During this period, you will not find it easy to taper off zolpidem further. Mirtazapine (Mirtaz) would be a good choice but the dose you were taking was just the starting dose. Please discuss with your doctor regarding a hike in the dosage.

Addition of a second medicine just to improve sleep is another strategy that can benefit you. Calmpose and Frisium have so far been tried in your case, but there are other options as well. Quetiapine (in immediate release formulation, not extended release) would be a good choice. It is basically an antipsychotic medicine at higher doses, but can be used just to improve sleep in low doses. Please also discuss with your doctor regarding the addition of quetiapine to your prescription. A combination of mirtazapine and quetiapine will help you taper off zolpidem, but it will take time. Once you start the medicines, try reducing zolpidem slowly, say by just 10 mg per week. If you find this easy, then you can try hastening up the process. Do not try to stop abruptly.

Please do not stress yourself unduly. You have already made a lot of progress and will surely manage to come out of it. It is just a matter of time and some patience. Do not doubt yourself or feel ashamed about this. Everybody makes mistakes and so did you.

Please let me know if you need any clarifications. Have faith in yourself. You can do this. You just need some guidance and support.

Best wishes.

Dr Preeti Parakh
MD Psychiatry

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Brief Answer:
Sorry, I am not allowed to do so.

Detailed Answer:
Hi XXXXXXX

Nice to hear from you again. It is unfortunate that your doctor is not available at this time, which is so crucial for you. I wish I could have helped you further. However, the rules of the website do not allow doctors to mention the doses of medicines or provide a prescription as an online consultation cannot take the place of a visit to a doctor in person. Please try to find a psychiatrist in your city who can assess you in detail and provide a prescription. Discuss the option of adding quetiapine to your antidepressant (Mirtaz) when you consult the psychiatrist. Till then, you should continue with the medicines your previous doctor had advised. Please do not remain off treatment even if you feel that it is not making much of a difference.

With sincere regrets,

Dr Preeti Parakh
MD Psychiatry

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Brief Answer:
It will be better to consult a psychiatrist.

Detailed Answer:
Hi XXXXXXX

Mirtaz is an antidepressant which also has the side effect of sedation. Hence it is a good choice for those depressed patients who are troubled by sleep problems. I expect the dose was increased to 15 mg recently, and if so, you will see the benefit over the next few weeks. Trazodone is also an antidepressant with sedative action. It is not very effective as an antidepressant, but is usually added to a more effective antidepressant to improve sleep. That way, it is good for you to take it. But please keep in mind that it rarely can cause priapism (persistent painful erection) as an adverse effect. Frisium contains clobazam which is a long acting benzodiazepine, commonly used in seizure disorders. It also can cause some sedation. Fluoxetine is an antidepressant which takes around six to eight weeks for response. You have not mentioned what dose you are on and how long have you been on it.

In my opinion, you should continue with Mirtaz and Trazodone. Instead of Frisium, I feel that quetiapine (immediate release) will help you more in insomnia. About fluoxetine, I am not sure. I would need to know how depressed you were and currently are, how long you have been on it and the dosage, and how did it benefit you, in order to be able to give an opinion.

If it is not too difficult for you, then do try to find a good psychiatrist. Till then continue with the medicines you are on. Meanwhile try to reduce your zolpidem intake by 10 mg every week. If it is uncomfortable, then you can do it even more slowly, say 10 mg every two weeks. Do not be in a hurry. Be slow but steady. Listen to your body and adjust the rate of tapering accordingly. Avoid tapering on those days when there is a heavy work load at office. Make changes on weekends so that you are reasonably well by Mondays.

Above all, accept the suffering. Each night when you cannot sleep well, tell yourself that the suffering is transient and you will get well eventually. It is just a matter of time. Do not give in to despair. Be positive. XXXXXXX your back after each reduction in dosage and celebrate.

Best wishes.

Dr Preeti Parakh
MD Psychiatry

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Brief Answer:
Propranolol may be tried.

Detailed Answer:
Hi XXXXXXX

The tremors that you are experiencing are due to withdrawal. I expect you might have noticed that the tremors are reducing gradually. Withdrawal symptoms can be reduced by taking the medicine which was being reduced. So, your tremors will improve when you take zolpidem or any medicine which is similar to zolpidem, e.g., eszopiclone. However, this would bring you back to where you started.

Instead of taking more zolpidem, try taking Frisium and see if helps in the tremors. Frisium, Calmpose and similar medicines are structurally different from zolpidem but work at the same receptors. These may help in the withdrawal symptoms to some extent. But please keep in mind that these medicines are also addictive, in fact, far more addictive than zolpidem. Please be careful and do not take in excess.

Propranolol (Inderal) is helpful in tremors due to other causes. You can also try a small dose of this and see if it works. It has no risk of dependence but can lower the heart rate and blood pressure. So it must not be taken by people who have low blood pressure or heart rate.

Do not taper off zolpidem further till tremors are gone. It may take one to two weeks. Just have patience.

Best wishes.

Dr Preeti Parakh
MD Psychiatry

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