Time to put my brain in its place
February 21, 2016 10:15 AM   Subscribe

After many years of struggle with depression and constant, needless anxiety, it seems that my issue is primarily or purely chemical in nature. But my medications aren't really working right now. What options should I be looking at? What might my treatment look like?

I've always been very anxious, with spikes here and there. A little over three years ago, this developed into clinical depression and generalized anxiety. A year ago to date, I started on Zoloft, which gradually increased to 75mg. This seemed to do the trick -- I found it very easy to redirect my attention away from anxious thoughts, I was able to restore my sense of self-worth, and I functioned very well socially. But over the past couple of months my anxiety has spiked again. With my GP, I tried bumping the Zoloft up to 100mg, but three weeks later this has had no discernible effect. In the meantime, the anxiety consumes every minute of every day. I have had numerous panic attacks, and at one point I spent all day in bed, not eating or going to class.

So I decided I needed something that was more specifically anxiolytic, and shorter-acting. My GP had me try hydroxyzine, which did jack shit. I was miraculously able to get Klonopin from an urgent care on Wednesday. I started at .25mg twice a day, bumped up to .5mg, now I'm at .75mg... it may be taking some of the edge off, and I have definitely had some unusually good moments, but it's not really having much of an effect beyond that.

Here's the thing though. I've been in therapy for over a year. I've done lots of CBT, and integrated it very well into my daily life and thinking. I have a well-formed set of rational beliefs and values which I have worked through with my therapist and used to determine that my anxiety is baseless. I have been a devout Zen Buddhist practitioner for a year now, which has helped me accept my anxiety more and has ingrained mindfulness deeply into the fabric of my thinking. I meditate very regularly. Most days I go for long walks outside, for exercise and fresh air. None of this has made a dent in the continual haze of anxiety underlying everything I do.

So what options am I going to be looking at to get relief from this? I'll be in to see a psychiatrist soon. What sorts of medications should/will be on the table? Is Klonopin just not going to work for me, or do I just need a higher dose? Would it be reasonable to add a veeeery small supply of Xanax PRN in the meantime? And what do I do about the Zoloft?

Thank you all very much for your help. It is deeply appreciated.
posted by myitkyina to Health & Fitness (18 answers total) 10 users marked this as a favorite
BuSpar is often used to augment SSRIs like Zoloft in the treatment of anxiety. You could ask your doctor about that.

It might also be worth trying a different SSRI.

Having a low dose of Xanax on hand is definitely reasonable.

Good luck!
posted by schroedingersgirl at 10:29 AM on February 21, 2016 [3 favorites]

Zoloft didn't work for me, and in fact encouraged suicidal thoughts. My psychiatrist put me on Remeron (plus Xanax as needed) and it works well. Once you're in to see a psychiatrist rather than just a GP they should have the expertise to help you find what works for you.
posted by MsMolly at 10:45 AM on February 21, 2016 [1 favorite]

Does your GP know that you are on klonopin? Benzos loose their efficacy quickly and if klonopin 0.75mg twice daily isn't cutting it now then I would definitely reconsider going down the daily benzo route without consulting your psychiatrist or PCP asap.

Buspar takes a long time to work. Like, 3-6 weeks.

If I were you I'd talk to your doc about getting an order for an as needed Ativan or Xanax.

For what it's worth, my most anxious friend has transformed her life with Paxil. She is a fully functioning, calm and reasonable person now. I know that the sexual side effects and discontinuation effects make it a little iffy but it's worked so well for her. YMMV obviously.
posted by pintapicasso at 10:51 AM on February 21, 2016 [2 favorites]

I know it's hard, but try to trust that the psychiatrist - which is definitely the right thing for you to be doing next - will work with you to figure out the very best course of treatment based on their training and experience AND your reported experience, and you do not have to figure it out for them ahead of time. Not knowing is anxiety-producing, yes, but the answer to your question at this point is "literally almost anything."

Or "nothing at first" - there may be no change yet, except possibly some kind of rescue benzo if they think it's appropriate - until you get a full bloodwork panel (if your GP hasn't done that this year already, or possibly a second one to compare) so your thyroid, A1C, vitamin D/B/K levels, etc are known to flesh out the bigger picture. You may also end up with a referral to an allergist too, for testing. It's one of the advantages of seeing an actual psychiatrist, they're going to look at a larger medical picture than your GP or non-MD therapist will.

What you will do about the Zoloft is nothing until they say to do something. Zoloft is one of those meds that needs stepping down under supervision. If you are worried about that process, make yourself a bullet point (on the list of notes you will take with you to that meeting) to talk about a slower-than-typical weaning schedule.
posted by Lyn Never at 10:51 AM on February 21, 2016 [3 favorites]

Response by poster: Not to thread-sit...

Does your GP know that you are on klonopin? Benzos loose their efficacy quickly and if klonopin 0.75mg twice daily isn't cutting it now then I would definitely reconsider going down the daily benzo route without consulting your psychiatrist or PCP asap.

My GP does know. Do you mean that continuing to take the .75 mg with no effects will reduce its ability to have an effect at higher doses? Should I try a full 1mg tonight or something? I feel that a daily benzo is the only thing that is going to be able to get me through this while I work out a long-term solution.
posted by myitkyina at 10:55 AM on February 21, 2016

Those are questions for your doctor.
posted by pintapicasso at 10:57 AM on February 21, 2016 [1 favorite]

My flavor of being mentally interesting is bipolar, but the process is similar when it comes to medication. Some work, others don't. Some work right away, some don't seem to work for over a month then it's like a light went on and everything that was wrong is right again. Then there are those that make everything terribly terribly wrong. The point is... it's different for everyone and no one here can tell you what will work for you.

Listen to Lyn Never's advice. Don't do anything until you talk to your psychiatrist. They kinda know what they're doing when it comes to medications.

Psych meds are nothing to mess with on your own...
posted by patheral at 11:01 AM on February 21, 2016 [1 favorite]

No answers on meds, but the therapy called Somatic Experiencing changed my life. I was on multiple meds for depression and anxiety for decades with only short-term relief. Now I occasionally take klonopin when I can't sleep. I still get depressed sometimes, but it is more like what most people experience as blues. It seems to be related to stress in my life rather than coming out of nowhere. It goes away by itself in time. I also thought my depression was chemical in nature and would always have to be managed by medication. YMMV of course. And also, of course, never go off of meds without the supervision of a doctor.
posted by FencingGal at 12:07 PM on February 21, 2016 [1 favorite]

My experience: low blood sugar and allergies can promote adrenaline spikes, fueling anxiety.

You could get checked for those conditions. Getting blood sugar problems and allergies under control has dramatically reduced my anxiety levels.
posted by Michele in California at 1:47 PM on February 21, 2016

Benzos don't always lose effectiveness over time. Not for everyone. When your problem is essentially chemical, the drugs seem to keep working the same way for as long as you take them. It really is different for everyone. I know someone who takes 200 mg of Zoloft a day for panic attacks, because once they switched to generics the bioavailability was effected, but has been taking it for almost 20 years. I take, and have taken xanax every day for a few years, between .5 and 1 mg depending on manufacturer, because I am an oddball and it is the only benzo that I can tolerate.

I tried for years to find other ways to manage anxiety, tried lots of meds (hydroxyzine is an early antihistamine, lousy for allergies but great for sedation and makes me miserable). Eventually you may need to ignore what everybody else "knows" and do what works best for you. Doctors and pharmacists who don't know me are damn hard to convince regarding my personal cocktail, but it is my life and my body and I am the one who spent years to get to a decent level of function. It is scary to try new things, but not living in anxiety, panic, and fear of both is worth pretty much anything it takes to get there. Even meds that other people dislike.

P.S. the person who takes Zoloft for panic attacks also takes daily clonazepam for anxiety. Has for years, because it works. Benzos get a bad rap, but sometimes they're the best tool for the job. Take care of yourself.
posted by monopas at 1:50 PM on February 21, 2016

If one ssri stops working, a different one might be effective. Each one affects various people differently -- it's not like some drugs where side effects and benefits are very similar within one class. It's common to move to another ssri if one doesn't help or stops helping.

It's awesome that you've developed several ways to lessen your anxiety and improve your functioning. It can be very hard to benefit from CBT, meditation, etc. when your general anxiety level is very high. I'm sorry you're going through this. It's totally normal for an anxious person to feel anxious about the next step in treatment!
posted by wryly at 2:22 PM on February 21, 2016

Keep working with your GP and/or psychiatrist on those drugs. But in addition to that, have you had routine bloodwork done? There are some medical conditions that can also contribute to anxiety, e.g. thyroiditis. If you haven't had a regular medical checkup lately, it'd be worth asking for one.
posted by pie ninja at 3:30 PM on February 21, 2016 [1 favorite]

You can talk to your doctor about increasing your Zoloft dosage - I take 200mg daily, which I think is the maximum dosage. I've tried a lower dose and it didn't work for me.

There are also other medications you can take along with an SSRI to boost the effect - Abilify worked very well for me, though I no longer need it. Lamictal is another popular one - it had zero effect on me, but I know others who have found it really helpful. I have some friends who take Wellbutrin in conjuction with an SSRI and find that combination works well.

It's really common for a medium dose of an SSRI (which is what 100mg Zoloft is) to be insufficient. There are a ton of options you haven't tried yet, and your psychiatrist will be able to help you figure out which option to try next.
posted by insectosaurus at 8:36 PM on February 21, 2016

I take 200mg of Zoloft and a twice-daily low dose of klonipin to keep my anxiety and panic attacks at bay. 100mg of Zoloft did nothing for me. This current routine (plus lamictal for mood stabilization) is working fairly well after over a year of trying every med under the sun.... It sucks, but it's definitely worth it to be persistent.
posted by celtalitha at 10:38 PM on February 21, 2016

For what it's worth, my most anxious friend has transformed her life with Paxil. She is a fully functioning, calm and reasonable person now. I know that the sexual side effects and discontinuation effects make it a little iffy but it's worked so well for her. YMMV obviously.

I can second everything mentioned about Paxil. Anxiety isn't my primary issue anymore (lots of CBT and counselling worked wonders), but back when it was, my goodness if Paxil didn't wipe out anxiety completely. I find sexual side effects fairly minimal but discontinuation very, very unpleasant.

I Am Not Your Psychiatrist, but I had it explained to me that Paxil's mechanism of action means it produces a big flood of serotonin when metabolized rather than a consistent release throughout the day, which makes it preferable if anxiety is the key issue.

Talk to psychiatrist. Also worth considering that some psychiatrists are more informed about drugs than others (some emphasize talk therapy more; if your issue is purely chemical you don't want one of those.)
posted by iffthen at 12:07 AM on February 22, 2016

But over the past couple of months my anxiety has spiked again.

Realising that I got especially depressed and anxious every winter was a huge deal for me. I fixed my Vitamin D levels and it changed how I feel every January and February DRAMATICALLY. I'd advise you to get your levels checked, and in the meantime if you live in a non-equatorial place just assume they're terrible and try either a good strong supplement, light therapy, or both.

I can't advocate it enough. I went from one year nearly relapsing into self-harm, to getting into February feeling... like me. Just normal, everyday me. Such a difference.
posted by greenish at 5:55 AM on February 22, 2016

I'm so sorry you're going through this. Panic attacks - you can treat a panic attack physiologically with cold water on your face. I was on medication that gave me panic attacks and had one in my therapist's office. A cold wet washcloth on the face stimulates nervous system responses that help stop the attack. For a long time I carried a washcloth in my bag, just in case.

Other things that help me - time spent with dogs, time spent with babies/ nice kids, sunshine, outdoors, music.

I wish you the very best.
posted by theora55 at 6:20 AM on February 22, 2016

I strongly discourage stepping up the benzos on your own without the oversight of a doctor, ideally a psychiatrist. Benzos are habit forming (i.e. addictive) and have serious withdrawal symptoms, not to mention worrisome long term potential effects.

If you can avoid being on a daily benzo, trust me, you should. If you need it to function then you need it to function but explore your other options first.
posted by treehorn+bunny at 7:18 AM on February 22, 2016 [1 favorite]

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