Do I need a higher dose?

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I have been on psychiatric meds for many years now. On a daily basis I take Amitriptyline for depression, Zopiclone to sleep and Sodium Valproate as a mood stabiliser. My doctor also gives me 7 x 5mg Diazepam monthly to take as and when needed. 

Although diagnosed with depression and generalised anxiety I coped ok with these meds but about a month ago (for no reason I can pinpoint) my physical anxiety symptoms became a daily occurrence and more debilitating - they are tremors in the hands (unable to do fine motor movements) a certain kind of muscle tension/pain in my back and neck and palpitations

I went to see the my GP and told him what was happening. The only thing that I knew would help was diazepam but I knew my GP wouldn't give me more of those! Instead he suggested Propanadol 10mg morning and evening. That was a week ago and at first they were great but yesterday and today they are not so good. The symptoms start almost as soon as I get up and today the propanadol didn't seem to kick in for a couple of hours and now 8hrs later they are wearing off again.

Is this usual - I would have thought the opposite would have happened as they built up in my system? Should I go back to the GP and ask to up the dose or just soldier on? I've noticed from my reading that 10mg twice a day seems to be quite a low dose.

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8 Replies

  • Posted

    All I can suggest with this is give the medication time to work. You will need to get a buildup of the medication in your body

    Keep clam and Good Luck

    BOB

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    • Posted

      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. 
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    • Posted

      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

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    • Posted

      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

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  • Posted

    Hi Drewa,

    No, what you describe is certainly not usual. Propanolol is a fast acting CNS depressant, it does not need time to ‘build up’. I would strongly advise seeing a psychiatrist because the mix you’re taking looks controversial. Firstly, diazepam and zopiclone (or any other benzodiazepine or nonbenzodiazepine) should not be used in combination with valporates, unless the benefits outweigh potential risks. The tremors that you experience may be caused by excessive depression of your central nervous system resulting from taking three (!!) depressants at once. Secondly, it is not OK to rely on diazepam over many years. Maybe you got to the point where the 5mg dose doesn’t work anymore…? Your GP did the right thing when he refused to prescribe more diazepam, it wouldn’t help in the long term.

    In my opinion your body may have adapted to the medicines you’ve been taking, especially taking into account that all of the drugs on your list besides amitriptyline do not treat any condition, they just mask the symptoms. I think your case may require a more comprehensive approach and should be referred to a specialist. One way to move forward would be to give up diazepam, zopiclone and sodium valproate and replace them with one of the newer atypical neuroleptics with an activating profile – eg. risperidone or aripiprazole. These would take care of the anxiety, enable you to sleep and remove all psychotic symptoms. Furthermore, sodium valproate could be replaced with lithium (which have a different side effects profile – maybe it would suit you better?).

    Anyway, please – do yourself a favour and see a specialist!

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    • Posted

      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.

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    • Posted

      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.

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