Question: Hi Dr. Seikhoo:

This weekend marked my first full week with tianeptine sulfate, 15 mgs Nardil, 100mgs lamictal. I thought I would have a clearer sense of where to go from here (continue discontinuation of Nardil or increase my dose) but I do not.

The irritability with clients and family members has been increasing: My thoughts are racy during day and sleep (I feel like three voices are talking in my head all night and there is a feeling of dread) and I wake up angry, fractured thinking, and directionless, and sad. I continue to have problems with verbal communications, my sex drive was increasing before the tianeptine but have dropped. I also feel a little more anger and daily headaches since starting the tianeptine.

The irritability, concentration problems, and meanness with clients was definitely a problem before taking any medications. It is detrimental to my family and client relationships, and I feared it would return when I stopped the Nardil (It helped tremendously). This is the most important issue to me right now. These people can sense my anger and are becoming afraid of me.

I may be incorrect but I feel the "three streams of thought going through my head" especially at night; the anger, loss of sexual interest, and headaches have increased on the tianeptine.

I find the confusion, mood, and anger gets less somewhat better if I take the smallest bit of ritalin (2.5 mgs) but my behaviour becomes impulsive again (drinking, smoking, avoiding people to go fishing). It does not seem like a good solution. Conversely, Modafinil now makes the spinning thoughts and anger a little worse.

This morning I didn't take the tianeptine sulfate to see if anything changed. Irritability was just as bad, and mood may be decreased, but the extreme busy thinking doesn't seem to have kicked in. Slightly improved sex drive.

I think I told you I would check in after one week of tianeptine to discuss a path forward.

Thank you for your help. My doctor is friendly and open to new ideas but has little experience and can't offer much insight. We had discussed total nardil discontinuation and then starting clomimpramine, but the more I read about it, it seems to have the same problems with apathy as an SSRI but with more physical side effects. I wish I had better options to go forward with.

typically small doses of serotonergic meds tend to make me somewhat irritable. I was angry at 20mgs of Nardil before I went up to 30 mgs, and when I tried to stay at 10 mgs celexa it was similar.

So this morning I omitted the Nardil in the morning and only took tianeptine 25 mgs and 100mg lamictal. Adding 2.5 mgs ritalin helps with the communication and focus. 5mgs of propranolol is helping with the agitation to some degree (strange effect, no?)

I will continue to ramp down on the Nardil and take half a pill before bed going forward.

Is it considered safe to take 50mgs of tianeptine sulfate per day, BID? I don't want to get in the territory of too much opiate activity and subsequent withdrawal problems.