Klonopin withdrawal or re-emergence of anxiety???
Erin writes in with a very common question:
I am coming off Klonopin. I am currently at .25mg. and have been for three nights. Does the withdrawal symptoms have a peak and then they get better? I really want to stick it out but I am feeling pretty crappy.
There are a number of factors that go into the answer for this question. First (and sometimes easiest) issue is this–do the current symptoms that you have feel like the anxiety that you used to have before the Klonopin (or other anxiety medicine) was started? Klonopin, like other benzodiazepines, is no cure. It helps to alleviate symptoms while it is present, but, once removed, previously experienced symptoms may return. If what you feel is that old demon anxiety . . . it has little to do with ‘withdrawal’ from Klonopin. It just isn’t there to work anymore. The solution may be to restart the Klonopin at the last effective dose, and/or try an antidepressant that has antianxiety efficacy, and/or do some hard work with a cognitive behavioral therapist. It is certainly possible that what you are experiencing is true withdrawal symptoms from the absence of the Klonopin. That would depend on several factors including: (1)how high a dose you were on (if you were on really high doses you might have more difficulty getting off), (2) how fast you are getting off (more likely to have anxiety and withdrawal with a quick taper) and (3) your own biological sensitivity (cannot measure that but you know yourself better than anyone else).
Regardless of the reason for the difficulty, what I typically do if someone is having a difficult time coming off the medicine is to go back to the last dose that was effective and then slow down the taper schedule. Unless you are in a particular hurry (eg, getting pregnant soon), it may be better to make the taper schedule very long and slow. The duration of withdrawal symptoms can be anywhere from a few days to a few weeks. Typically, 7-14 days is sufficient to wait out withdrawal symptoms . . . but who says you are typical! But seriously, if you did the standard taper of 0.5 mg Klonopin for a few weeks and then go down to 0.25 mg for a few weeks you are unlikely to be experiencing “withdrawal” unless you have a particular biological sensitivity. Again, that would be addressed by a more gentle taper. Talk to your psychiatrist about going down by 1/4 tablets rather than 1/2 tablets every few weeks or so.
The following url will get you to the website for the American Academy of Family Physicians. Once there, type in Klonopin withdrawal and you will get a good overview of benzodiazepine withdrawal symptoms and the management of it.
Hope you feel better soon.
–Dan Hartman, MD
Combining Effexor and Cymbalta–a good example of what not to do
On the search engine terms on my blog stats the other day, I had “combining Effexor and Cymbalta” listed multiple times. LIKE 25 TIMES. Seems someone had a question that was not getting answered too quickly. It brought to mind, once again, how mysterious these medications can be to people. To most folks (and some psychiatrists it seems), an antidepressant is an antidepressant is an antidepressant. This is just not true. Different antidepressants hit different receptor sites and there is no reason to combine antidepressants with similar mechanisms of action. In fact, this could be down right dangerous. Combining like-antidepressants can put you at risk for serotonin syndrome and put you at risk for potentially dangerous increases in your blood pressure. Also realize that ANY combination of antidepressants is outside the standard FDA guidelines and should always be accompanied by a good explaination of why this treatment is being recommended. Combining antidepressants is a standard of practice at this point, but, again (and again and again), must be accompanied by a solid explaination.
With respect to the above combination of Effexor and Cymbalta–highly unusual. Cymbalta (a true dual-action antidepressant) works on both the norepinephrine receptors and the serotonin receptors. Effexor (a quasi-dual acting agent) works on the serotonin receptor and, at higher doses, on the norepinephrine receptor. I cannot even see where using this combination would make any sense, but, if your psychiatrist is recommending it, make him or her explain their reasoning behind it. If they can’t (or won’t), don’t accept it.
That is generally good advice for dealing with any physician who is prescribing any medicine.
–Dan Hartman, MD
Trial of no medicine–knowing when to stop and think
There comes a time in my work with some of my patients that I have to stand back and say . . . “what are you doing???” When patients come in with a cascade of difficult problems, the knee jerk reaction is to change the medicine. Initially, this might be adding an antidepressant (say . . . Zoloft). Then, there seems to be a lot of anxiety. So I add in a benzo (say . . . Klonopin). Then, the depression continues to muddle along and we think about adding a complementary antidepressant (say . . . Wellbutrin). Then, there are some sleep problems, so a sleeping aid (say . . . trazedone) gets added. Then there is some breakthrough anxiety and we need a ‘once in a while’ antianxiety agent, so we add a short acting benzo to address these times (say . . . Xanax). Next thing you know, I take a look at the list of medicines, and . . . YIKES!!! . . . this nice person who came to me for depression is on five different medicines . . . and not necessarily doing too well. Or, there might be dramatic improvements, only to be followed by a gradual return of symptoms over the course of weeks or months.
I’m glad to say that this is more the exception than the rule. Most of my patients do not end up with this type of extensive medication cocktail, but it is far too easy for this to happen (easier than I’d like to admit) and I’m sure many of you can relate. It seems that a doctor’s natural reaction to a patient coming in with a difficulty is to prescribe more medicine. Let it be known that, it is also the natural reaction of the patient to EXPECT that the doctor prescribe more medicine. When someone comes in feeling depressed or anxious, my attempts to get them to make changes to their life-style (diet, exercise, meditation etc) or, to just experience the mood and talk about it in therapy, is rarely greeted with enthusiasm. While there are certainly a great many situations where the pattern of symptoms are spiraling out of control, there can also be cyclical patterns to some people’s experience of mood and anxiety symptoms. Things are ok for a while and gradually become worse, then gradually become better, then gradually become worse, etc, etc. If you come to the doctor at a time when things are not good, and the doctor prescribes a medicine and things get better, the doc looks like a wizard! Truth is, often times, if we just sit on our hands and do nothing, things might get better too. When you see your doctor, keep your mind open to the option of doing nothing with the medicine and seeking life-style and therapy options that may be more beneficial in the long run.
But anyway, I digress. The original point of this blarticle was to discuss the need at times of getting off the medicine and seeing what happens. How many of you have experienced feeling lousy off the medicine and, honestly, not feeling that much better on it. There does come a time where, when multiple medications have been tried, it seems best to admit you just aren’t sure what is going on, and it is time to try a little bit of nothing. Now, when multiple medications are being used, the titration down for each of them must be carefully planned and the patient MUST adhere to the plan very closely. Slowly tapering the medicines minimizes the risk for rebound symptoms or discontinuation symptoms. In addition to the gradual decrease in the doses, there must be support people in place to keep an eye on the patient so that, if the crap hits the fan, there is someone there to help. Decreases in the medicine should (of course) be accompanied by all of the usual stuff that helps people’s mood be better (detailed in other blarticles). Back in the day, we used to be able to do this in the hospital. It was almost a standard practice to get someone off medicine, and observe them for a few weeks, and, once reassessed, re-apply medications as needed. Unfortunately, this was overused, and, now, is simply not available (unless you have deep pockets and can pay cash–no one I know!). It is still a method that can be used in the out-patient world, but everyone must communicate well and everyone must be careful. There is always the distinct possibility that things could get worse–much worse–off the medicine.
Anyone want to share their story about being on too much medicine and then coming off?????
–Dan Hartman, MD
Irritability during antidepressant trials
What does it mean when someone has a negative reaction to antidepressants? Most people put on antidepressants do well. They have minimal to no side effects and have a gradual improvement in their mood/anxiety. For some people, a trial of an antidepressant is a nightmare. Any time an antidepressant is initiated, you can experience irritability, aggression, a paradoxical increase in sadness, and even (in rare cases) a serious increase in suicidal ideation.
What does it mean?
Obviously the ultimate meaning of a bad reaction must be evaluated in the context of the complicated clinical and psychosocial picture of the individual with the reaction. It must not, however, be ignored. Here are several circumstances and a brief interpretation of what it could mean. Remember, these is just a brief overview–make sure you talk to your doctor:
MORE DEPRESSED: Suppose you get more depressed on an antidepressant. By that, I mean a nearly immediate drop in your mood when a medicine is started. It may be a worsening of the existing symptoms (eg, more fatigued, worse concentration, more difficulty enjoying yourself). It may also present as a dramatic emergence of symptoms that were not previously an issue. This is different than a continued gradual progression in the pattern of mood symptoms which would indicate a lack of effectiveness in the medicine rather than a negative reaction. If there is a dramatic worsening of symptoms, I typically stop the medicine and watch how things progress and change over the course of a few days or a few weeks. What I look for when someone is having this type of reaction on antidepressants is for his or her mood to return to the ‘regular’ amount of depression that was being experineced before the medicine was started. Once we get back to that baseline, I will try another antidepressant. Is there deep meaning behind this type of reaction. Typically not. This type of reaction to a medicine has little to no predicitive value for how someone will react to other medicines. If someone has a similar reaction to a similar medicine, that starts having predicitve value. For example, if both Celexa and Zoloft cause this type of reaction, I would be more reluctant to initiate a trial of another SSRI, and would choose a medicine with a different mechanism of action.
SUICIDAL: Worrysome . . . very worrysome. This type of reaction to an antidepressant is also very ideosyncratic and unpredictable. It also has no predicitve value, unless it occurrs again with a medicine that is similar in action (eg two SSRI’s). Anytime someone has enhanced suicidal ideation in responce to a medicine, it is time to step back and reinforce the psychosocial supports available to the patient. It is important that he or she understand the ’side-effect’ nature of the suicidality and how to manage it should it reoccur. Specific management strategies need to be in place, especially designated ‘rescue’ people–people who know that the patient is on medicine and understand the reaction that did occur and could occur with the next trial. Should an increase in suicidal thoughts occur, the medicine should be stopped and the patient carefully monitored until the pattern of thoughts decreases to the previous level. Having suicidal thoughts on one antidepressant does not mean that you will get suicidal thoughts on another antidepressant.
IRRITABILITY: This is an interesting reaction because it can have meaning . . . BIG meaning. Profound irritability on antidepressants can indicate the possibility of an underlying or emerging Bipolar Disorder. In patients who have a family history of Bipolar Disorder, it has greater predictive value. It has even greater predictive value in patients who experience an irritable reaction to two or more antidepressants, regardless of the class of the antidepressants. Does irritability mean that you have Bipolar Disorder. No. Only when the irritability is associated with other symptoms that are typical of Bipolar Disorder–eg hyper-talkativeness, decreased need for sleep, dangerous impulsive behavior, etc. Regardless of the presence of other Bipolar symptoms, if someone becomes very irritable on more than one antidepressant, it signals to me the need to start a mood stabilizer before initiating another antidepressant trial. Low or moderate doses of Depakote is usually my recommendation.
–Dan Hartman, MD
