As Needed Anti-Anxiety Medication In Conjunction With Seroquel

January 29, 2011 3:03 PM

I am wanting to ask my psychiatrist for an as-needed anti-anxiety medication. I'm being treated for bipolar II with Seroquel and am mostly very happy with it. I'd like to be as well-informed as possible when I see the doctor next.

As my mother has been treated for bipolar II for all of my life, and I've been on-and-off treated for the same since adolescence. 2010 was the year I made a solid for-myself-decision to get help. Seroquel is honestly the first medication in my memory that has helped me sooo much. I've done TONS of research and know all the things I should be watching out for. Almost a year later, and I haven't noticed any major adverse effects.

Seroquel has *mostly* helped. It's much easier to control my mood swings and the reactions to my emotions (dbt has also helped with that). I sleep well and have a healthy appetite. For the first time in my life, I'm getting rest at night and not battling depression-or-hypomania-induced anorexia.

I lost a job I really liked and cared about a couple of months ago. This has added WAY MORE stress and anxiety to my life. The Seroquel's still *mostly* working, but there's once or twice a week where I get to a point that I totally break down with anxiety/depression/general-stress-overload.

I cannot afford even every-two-week therapy while between jobs, at least, not if I'm going to keep up with the medications and the psychiatrist visits. I've got decent county-sponsored prescription coverage, so I'm hoping I can add another medication to my treatment; preferably this would be an *as needed* anti-anxiety solution, temporarily during this high-stress period while I look for a job.

Seroquel has nearly 20 "major" drug interactions and 817 "moderate" interactions. (Source). This is a pretty long list, especially without any indication of how often these interactions occur.

Benzos (Xanax/Clonopine), frankly, scare me. Drugs I've been on in the past: Lithium is lethal to me. Gabitril didn't do much. Risperdol had side effects I couldn't deal with.

**TL;DR
I'm looking for an as-needed, temporary anti-anxiety medication which will be safe to take with Seroquel. Anyone on a combination like this? I know YANMD, looking for experiences and/or assistance navigating the available info in order to educate myself before seeing my psychiatrist.

posted by MuChao to Health & Fitness (22 answers total)

Best answer: If you take clonazepam/Klonopin on an as-needed basis, you should be fine. I take it when I'm amped up flying or when I need to sleep. It doesn't make you a zombie or knock you out, it just makes things okay. However, a friend of mine did take it every day for several years. I would not recommend doing that. Her withdrawal was painful to watch.

That said, seriously, those who have taken it in my family love it. One family member routinely states that the person who made it should receive the Nobel Peace Prize.

Talk to your doctor about it and start with a low dose so you can see how it affects you.
posted by kat518 at 3:22 PM on January 29, 2011

Clonazepam. I also have bipolar II and I take .25 mg before bed, but I will take it occasionally during the day if I become very anxious. I find it's effect to be relatively mild - it never makes me tuned out or fuzzy. I did take it with Seroquel for a while, so they should be fine together. For what it's worth, Seroquel was too strong for me.
posted by kitcat at 3:25 PM on January 29, 2011

Why do benzodiazepines scare you? That might be helpful information. If it's because of the potential for abuse, as far as I know, the same holds true for all anxiolytics, not just benzos (with the possible exception of SSRIs, but I don't think you take those as needed).
posted by J. Wilson at 4:18 PM on January 29, 2011

Response by poster: Benzodiazepines scare me because of the habit-forming and abuse potential. I have some recreational drug abuse in my past (the hard way to learn that over-dosing or quitting cold turkey can cause seizures).

Also, there's potential (with historical back-up) for insurance mix-ups and Dr's not checking voice mails, and being unable to afford the copay, and I don't want to risk being on a benzodiazepine and one day running out and not being able to get a refill for whatever reason (due to seizure risk mentioned above).

I'm told that taking them on an as-needed basis runs less of those risks, but with the history of abuse, it's a risk to my sobriety that I'd rather not take.
posted by MuChao at 4:30 PM on January 29, 2011

Best answer: Benzos are what most doctors prescribe for as-needed anxiety. Sometimes they prescribe beta blockers or Buspar, but I think those have to be taken regularly.

Honestly I don't think you have many options. Maybe an antihistamine?

Or discuss it with your doctor?


Wiki article on anxiolytics.
posted by elsietheeel at 4:36 PM on January 29, 2011

All as-needed anxiolytics work the same way, that is, by stimulating your GABA receptors (as does alcohol). So if you need them, take whichever one you like (different people like different ones) but they all cause habituation (after taking them for a while, they lose their effect and when you stop taking them, you get MORE anxious). Might be better in the long run to bear the stress. Supposedly anxiolytics with a longer duration of action (e.g. valium) as less addictive than ones with shorter duration of action (e.g. ativan). More information here.
posted by kevinsp8 at 4:36 PM on January 29, 2011

MuChao, I'm really surprised you are only getting Seroquel. Most folks have that as a secondary med?

That having been said, the best person to guide you in this manner is your doc. Everyone is different and it might be that lamictal or another med like Keppra might be helpful.

Forget us and just tell your doc what you need.


(Another option is to just work thru the anxiety? Normal folks deal with this as well and it's a good skill to have. Once a week is actually pretty good. Having said that you are the one who is having to deal with it and if the anxiety is truly crippling, go get it taken care of.)
posted by St. Alia of the Bunnies at 4:40 PM on January 29, 2011

Oops, my link didn't work. More info on problems with getting off anxiolytics here
posted by kevinsp8 at 4:52 PM on January 29, 2011

Here (damn)
posted by kevinsp8 at 4:53 PM on January 29, 2011

If you don't want a benzo then you're pretty much just left with counting to ten, breathing deep and getting more exercise. Try those out, and if they don't work go see a psychiatrist and request that they keep your dosage low. You are probably not going to get addicted to benzos if you need one or two a week for a few weeks. The fact that you are aware of your potential for substance abuse also will probably help you more than hurt you. Anyway, feel better!
posted by richrad at 6:33 PM on January 29, 2011

I am also bipolar, and I take Seroquel (along with 4 other meds). I also am a recovering drug addict, and I can't take benzos. Doctors who deal with co-occuring mental and addictions disorders have to get more creative than the average psychiatrist. Not all, but I got lucky enough to find one who looked outside of the usual solutions.

A possible option for you is Clonidine. It's a blood pressure medication that isn't habit-forming and the only real side effect is potential drowsiness. I take it PRN for anxiety, and in higher doses to supplement the Seroquel for sleep.

I would be happy to tell you (or anyone else) more about my experience with it but it took me three times to come back into this thread to write this-- I'm so triggered by some of the comments that I'm shaking. Please PM me if you want more info.
posted by mireille at 10:07 PM on January 29, 2011

Sometimes they prescribe beta blockers or Buspar, but I think those have to be taken regularly.

I'm a musician/music educator and in grad school, and I know people on both beta blockers and Buspar. I'm on Buspar at the moment, and it's the bees knees as far as I'm concerned. You do have to take it regularly, though. It plays nicely with Wellbutrin, but I don't know how it'd work with Seroquel (I know they're very different drugs).

Buspar is on Wal-Mart's $4 scrip program, so you could definitely afford the pills if you could get the scrips. I used to use benzos, but went with a long-term pill as a solution because I do have anxiety disorders. If you do deal with anxiety a lot, besides the short-term stresses you're dealing with, it may not be a bad solution.
posted by SNWidget at 10:08 PM on January 29, 2011

SNWidget: "Buspar is on Wal-Mart's $4 scrip program, so you could definitely afford the pills if you could get the scrips."

Unless it's changed recently (and it may well have), only the 10mg pills are on the $4 program. I take 40mg and have to get the script written as "take 4 a day" to be able to afford them.

I also take clonazepam (Klonopin) and one bottle will last me a few months during a not-terribly-stressful time. At my worst I'm allowed to take 1.5 mg/day but I can count on one hand the times I've needed that full dose.

If you're really against the benzos, I *think* beta blockers have an anxiolytic effect, but I'm not sure if your doctor would prescribe them. I think that would depend on other things like your blood pressure and such.

Some SSRIs have an anxiolytic effect. Not sure about SNRIs but Effexor (an SNRI) is the only thing that's worked really well for my depression. (Paxil worked but numbed me - you could have told me my best friend died and I wouldn't have cried.)
posted by IndigoRain at 2:22 AM on January 30, 2011 [1 favorite]

Unless it's changed recently (and it may well have), only the 10mg pills are on the $4 program. I take 40mg and have to get the script written as "take 4 a day" to be able to afford them.

You're right. I only take 10mg a day of Buspar, and I wasn't sure what other people's doses were.
posted by SNWidget at 7:27 AM on January 30, 2011

Best answer: Another recovering alcoholic/drug addict/manic depressive w/panic disorder to boot -- what fun, right?

Disclaimers: IANAD IANYD IAJAKOTB (just another kid on the bus)

Are you talking anxiety or panic? Different animals, in my experience of them, neither of them fun of course but anxiety childs play compared to panic. Buspar didn't do much for panic, though it's helpful for me now, in the mix of other meds I'm taking, helps calm the raging seas. Seas which rage just one heck of a lot less now than ever before, seems my meds 'stew' is working for me as seroquel is for you. (Seroquel didn't do anything good for me when I tried to use it daily, it made me nuts, or, rather, more nuts. Though it did knock me down if/when I was really flying, it shot me out of the sky, and sometimes to sleep, too, if/when I'd been on the run for a while, and not sleeping much.)

I was on klonopin for long years; it was all I had that worked, truly. I never got addicty around it but I know that many people do, I absolutely understand the respect you have for benzodiazepenes. It's very strange that I didn't get all twisty behind it, as I've never, ever met a downer I didn't just love. But I just never did abuse the stuff. Amazing, to me.

Anyways, buspar does help me, and I can take it as needed, too, I've got some in reserve to be able to have extra for those extra special days. It never, ever did shit in the face of breakthrough mania though, never took the terror of the panic attacks, never helped me sleep; it was as sugar pills, totally annoying, to be sure. Ambien the same; kids stuff. Ambien was helpful for sleep except in breakthrough mania, then ... Nada. Sugar pills. And lots of us (addicts) get into trouble behind ambien, too, maybe you can't take this one, either.

Benedryl can maybe help you with sleep, probably not in the face of panic but anxiety maybe. A bit of melatonin? Cute stuff, helps some of us. Has helped me, over the years.

I'm glad you're aware of the dangers of benzodiazepenes -- scary stuff. Lots of docs won't write for us anyways, if they are aware we're addicts, a good thing probably except that there are some of us out here who just nothing else will help.

As far as the cost of benzos, and ins not covering, Costco is where it's at; at Costco, klonopin costs less than M&Ms, almost. And you don't need a costco membership to use their pharmacy. See if you can get your shrink to write you for three months, three months of klonopin costs barely more than one month, plus you then don't have to hassle with it but four times a year....

Write if I can be of any help at all, even if just to commiserate - I know the terrain.

Good luck.
posted by dancestoblue at 9:46 AM on January 30, 2011

Best answer: Buspar, from what I recall, isn't supposed to be effective on as-needed basis - it's similar to an SSRI in that it needs a week to several to really take effect. There are some immediate side effects often that include drowsiness, and I think many people find that does the job. (I hope I'm wrong or haven't just popped a working placebo bubble.. if it works for you, fantastic)

Benzos have developed a stigma, and a well earned one - but they aren't scary like, say, cocaine, or opiates. You don't get hooked on benzos physically without chronic long-term or heavy usage. You can use them for your whole life on an as-needed basis, and as long as it's not too frequent (say even a couple times a week) it's no big deal. You could walk away.

.25mg of clonazepam (klonopin) or .25mg of lorazepam (ativan) will usually stop a panic attack almost instantly, especially the sub-lingual gelatin forms of ativan.

The biggest issue you will have is that they are generally contraindicated in people with a history of drug abuse, because withdrawal can be dangerous. You won't end up in danger territory after going through one scrip of small-dosage of either one - your only withdrawal symptoms would be difficulty sleeping and possibly an increase in anxiety for a short time. You and your doc will know pretty quickly if you have a "probleM" or not - if you keep coming back for early refills, it's not for you. If you only use them when you really need them, you can use them indefinately.


The danger is if you start popping them daily and in larger and larger amounts - there comes vague point where you can't just quit without risking serious complications, including coma and death (and that's only for something like 80% of the population - for some reason some people can still just walk away, at least as far as physical withdrawal symptoms go)
posted by TravellingDen at 10:51 AM on January 30, 2011

Response by poster: Thank you all for giving me a bit to think about. I do have personal experience of the Xanax overdose/withdrawal experiences. It does seem that the "lesser" benzos (clonapin/lorazapam) may not be as habit forming.

It has also been suggested that a low dose of Seroquel in *those* moments might be helpful and was what they were doing for me in the hospital. I'll occasionally break one of my 300mg pills and take a 1/4 of it, but the toss-up there is having my nightly dose when I need it. I might be able to afford another prescription at the lower dose.

Re: The Anxiety... may be more like what most people call panic attacks. I tend to downplay my problems a bit, and I've been corrected that I have more like 2-3 episodes a week since losing my job.

If it matters, I'm not really looking for something for every one of these episodes, but mostly I'm looking for something that acts fast when my panic/stress is preventing me from doing things I NEED to do such as going to interviews which just feeds into my panic and stress.
posted by MuChao at 11:55 AM on January 30, 2011

I don't have experience with beta blockers but I understand they are helpful for things like interviews if you're trying to get to a place where you can shake hands with a future employer without sweaty palms or so your mouth doesn't go dry while you're talking. I know someone who had to speak in public occasionally for work and it would really freak him out but he was prepared to speak, he knew the subject matter - it was just that he felt like his heart was racing - so he was considering beta blockers.

I don't mean to be pushy about klonopin so if that's how I come off, I apologize, but it may be worth a shot if you're looking for something for once or twice a week like you said in your question. There's also a generic so with my insurance, I pay about $5 for a month's worth. If I'm traveling, I might take it once or twice a month to help me sleep so a month lasts for a while.

That all said, I don't think I would use it before a job interview. YMMV but depending on how much you take, it's akin to having a drink and I don't think I would have a beer before a job interview either, even just to take the edge off. In my experience, it's better for when you feel anxious or generally uncomfortable. Someone I know has said that he's taken it before flying and ended up sitting next to a very large person but did not mind. I take long bus trips occasionally and there's usually one point where I just want off the bus so I've taken it to keep me from getting there.

I know you're concerned about potential for abuse but do you think your doctor would write you a few prescriptions - maybe just for 10 pills each - so you could try out something like beta blockers and maybe something else? This kind of thing might just be trial and error, I'm afraid.

Good luck - FWIW I'm sorry that you lost your job but I'm really happy that Seroquel is working for you. Finding something that works is a great feeling and I hope you get to experience it again soon :)
posted by kat518 at 2:17 PM on January 30, 2011

Best answer: MuChao: "It has also been suggested that a low dose of Seroquel in *those* moments might be helpful and was what they were doing for me in the hospital. I'll occasionally break one of my 300mg pills and take a 1/4 of it, but the toss-up there is having my nightly dose when I need it. I might be able to afford another prescription at the lower dose."

It might be that your pdoc can/will give you sample packs of seroquel, one of my shrinks used to have fistfuls of those 25mg in sample packs, little bitty pills, like a brown/red color. They are insanely expensive to buy in a scrip, and unless you get sample packs it's best to just bust up larger pills, for sure, but if you've got a good relationship with your doc it can't hurt to ask if he's got some samples of the smaller ones that he can lay on you for those 'special' times.
posted by dancestoblue at 2:17 PM on January 30, 2011

One data point: Personally, I've found Xanax to be milder than alcohol. And it's partially up to your psychiatrist to not prescribe you enough for you to overuse it and get addicted.
posted by Jacqueline at 11:02 PM on January 30, 2011

I think you sound like you're doing pretty amazing considering the circumstances. Even those not dealing with mental health issues would find losing a job they love very stressful. Benzos scare the heck out of me as well, also because I have the same diagnosis as you, and also with a history of substance abuse. Even the 'milder' ones can can set me off, because once I have even a taste, I will want more. I know that you mentioned that you cannot go to therapy, but there are other less expensive ways to get support, like talking to friends and telling them what is going on and letting them know you need support right now. There are support groups for all different types of things, maybe try some out? Also, cut yourself a little bit of a break..the feelings you are having are normal. It's normal to freak out and grieve a job loss. Give yourself a little time to heal.
posted by heatherly at 11:35 AM on January 31, 2011

Response by poster: Update: I talked with the doctor and we decided to add another, smaller dose of Seroquel to the middle of my day (with half that when/if needed; so far, not), as apparently Seroquel once a day never seems to be enough. So far, I've noticed quite a bit less of the irrational rage attacks and general anxiety.

So I guess so far, so good.
posted by MuChao at 6:20 PM on March 1, 2011