Do I need a higher dose?

Thanks for the quick response Bob but in my last paragraph I explained that I was puzzled because they were working better in the beginning and less and less well as each day goes on. 

Sometimes I suppose this may happen you will need to feel confident and allow time to work.

I can get impatient when things do not work straight away, I know in my case my medications took sometime to help me

Keep a Hold 

BOB

Thanks again Bob. Yes, I can be very impatient too, and unreasonable and easily irritated and frustrated! I know it can take some time for antidepressants to kick in but didn't think it would apply to this medication.

All medications like these take time I suppose, the problem is if you keep changing the worse it becomes to get a drug that will work. That is why I give everything a little bit longer.

When I became disabled it took them two years to match my medications and I was lucky that my Specialist went back to the beginning again to an earlier drug we had passed over. Some Doctors can get stuck on the outward journey and never return to a drug that seemed to be a problem as I had passed over it as not working well.  Sometimes allowing a little bit more time can stop a painful pathway

BOB

Hi there Johnkov and thanks for your very thoughtful and detailed response. Have you got a medical background? Anyway in order to answer it I think I need to give you some more info of my history.

I was a professional mental health worker for 15 yrs, albeit always on Amitriptyline (but none of the others). In about 2000 I started suffering palpitations which were confirmed by a cardiologist who deemed they weren't bad enough to treat. My GP told me that it could be a side effect of taking the Amtriptyline and as I had been on it for a long time we agreed we would see how I went without it.

Within 6 months of not taking it and being subjected to a number of severe situational stresses I had a fairly serious breakdown and was unable to work for some months. Two years later I had a much more severe breakdown and ended up in hospital under the care of a psychiatrist who eventually diagnosed me as Bi-Polar Type ll i.e. rapid cycling mood changes but no psychosis. At that point the Sodium Valproate was added in and seemed beneficial. Lithium was suggested but I was very against it because of how I had seen it affect some of my clients.

I continued seeing the same psychiatrist for about 5 years until I moved away and it was after MUCH trial and error that I ended up on my current cocktail. I found I couldn't take any SSRIs or Venlafaxine and eventually someone decided to ask the cardiologist if I could possibly go back onto Amitriptyline. Turned out he had never thought that was the cause, not did he say I should stop taking it!! I have had it ever since (10 years) with no signs of palpitations (except when I'm anxious). I am still very bitter that it's possible none of this would have happened if my GP hadn't taken me off the Amitriptyline in the first place.

I was lucky - because I worked in MH I could choose my psychiatrist and always saw him personally. When I moved away I was referred to another psychiatrist locally but was just a "normal" patient, seeing the 6 monthly rotation of junior doctors which I didn't like as there was no continuity.

Since then I have managed by just seeing my GP, but he seems very reluctant to change any medication diagnosed by a psychiatrist, and to be honest, until now, I have been mostly ok on it. The 7 Diazepam a month are for extremely anxiety producing situations and I often don't use any in a month. I do not think I am dependant on them, nor are they part of the current problem.

The only thing that might have a bearing, but I can't see a connection, is that about 10 days before this acute daily anxiety started I had decided to stop the Zopiclone. I was on a low dose (3.7mg) and didn't want to feel so groggy in the mornings. I had a few withdrawal symptoms for about a week but not much until the anxiety started. I assumed they were connected so reluctantly started back on the Zopiclone, thinking that would end it, but it hasn't and that's at least 4 weeks ago.

I could ask for my GP to refer me to a psychiatrist again, though I'm not sure he would think it necessary and part of me is reluctant because I know how much they like playing about with medication (because really there's little else they can offer!) and I had enough problems in the past trying various combinations. 

Don't know if this throws any light on the problem, and I'm sorry it's so long! Today has gone well so far anxiety wise. Because it took so long to kick in yesterday morning I took it when I got up to go to the loo about 2-3 hours before I got up properly and haven't had any anxiety at all today - it's now 6.30pm, so about 12 hours since the last one, so I am going to take the evening one now and see how that goes.

Hi Drewa,

No, I am not a medical doctor, I am a medicinal chemist who specialises in the research on psychoactive drugs. Probably this is the reason why I’m able to spot mistakes that most GPs are unaware off…

Thanks for providing more details about your condition, it is really helpful. I don’t think amitriptyline is the cause of your current problems, especially taking into account that it has been working fine for the past fifteen years. While it may cause cardiological side effects, these usually occur at the beginning of the treatment. In order to cause heart palpitations, the drug would need to inhibit noradrenaline transporter more strongly than expected – but again, this may happen at the beginning of the therapy. From time to time patients complain that the drug becomes less effective over time, but I haven’t heard anyone saying that it suddenly becomes stronger / more effective. This could theoretically happen if a patient developed another metabolism-related condition, something that inhibits certain liver enzymes (CYP2D6, CYP3A4) – this would slow down amitriptyline breakdown, which would result in elevated noradrenaline levels and heart problems (palpitations, hypertension, etc.). In a patient suffering from anxiety, these symptoms would certainly trigger a panic attack. But again, mind that I’m speculating here – only a GP could confirm this (e.g. run a blood test and look for elevated ALT/AST levels). Now, as propanolol is partially metabolised by CYP2D6, a mixture of propranolol and amitriptyline would require the dose readjustment of both meds. Did your GP consider that when he wrote the script?

As I wrote before, the mix of depressants that you take looks more suspicious. A cross-tolerance exists between benzodiazepines and nonbenzodiazepines. How often have you been taking zopiclone? Every evening?  A positive answer would explain why diazepam became less effective over time. In contrast to what certain pharmaceutical companies want you to believe, nonbenzodiazepines (all z-sleeping pills) have been confirmed to be equally addictive as benzodiazepines. Zopiclone should not be used for more than fourteen days… If you took it for a longer time, a physiological dependence may have developed. It should be tapered off; the dose should be reduced by a half every 2-4 weeks. If this was still too fast, you would need to follow the Ashton Manual (look for it on the web, I can’t paste a link as the mods would delete my post).

I hope this helps. And again – if you think that your current meds stop working or suddenly start working in a different/unexpected way, always try to see a specialist. They are there for us, even someone who you don’t know may turn out to be really helpful.