Brief Answer: No need to break it in half. Detailed Answer: Hi, Welcome to Healthcare Magic! Remeron (mirtazapine) is not a habit forming drug but is an anti-depressant. It is usually not associated with any withdrawal symptoms, least of all shakiness. Of all the medicines you are on, Ativan is the one that is commonly associated with shakiness when the level of the drug falls in the body. That is why you feel better after taking it. The other thing is that Remeron has a fairly long half life to allow for once a day dosing. This is another reason why it cannot cause withdrawal symptoms in the morning after a dose at night. It would remain in the body for longer than that. It is Ativan which has a short half life and can cause rebound anxiety when it leaves the body after a few hours. Remeron and Ativan have completely different mechanisms of action. In view of this, please reconsider if it is Remeron that was responsible for your symptoms or something else. Even alcohol can cause similar symptoms in the morning after a heavy binge. If you are sure that Remeron was responsible for your symptoms, then you can stop it at the current dose without reducing it further. The present dose of 3 mg is very low and can be stopped directly. I have prescribed it to many patients and so have my colleagues. We usually taper it down to 7.5 mg per day and then stop it. The purpose of tapering is more to assess if there is any relapse of depression and less to prevent withdrawal symptoms. As far as gastric irritation is concerned, both Paxil and Florinef are well known causes. Once you stop Remeron, it will be easier to assess if these too were contributing to the stomach discomfort or not. Please do not worry and stop the 3 mg dose directly. It is unlikely to cause you any harm. Best wishes. Dr Preeti Parakh MD Psychiatry

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Brief Answer: Quite possible. Detailed Answer: Hi, Yes, Paxil may be responsible. In fact, the controlled release preparation of Paxil (Paxil CR) was designed to reduced the gastric discomfort that was common in immediate release Paxil. If you are taking the immediate release version, shifting to the CR form may help. Best wishes. Dr Preeti Parakh MD Psychiatry

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Brief Answer: Explained below. Detailed Answer: Hi, Your rate of tapering off Paxil is fine. But I think your neurologist has not informed you that antidepressants should be continued for at least a few more months after you get well, for best results. I do not know whether you were prescribed Paxil or Remeron for depression or anxiety, but for both the usually recommended duration of treatment is one year. There is no sense in tapering off after just a few months and there is a higher risk of suffering from a relapse. The only medicine you should be in a hurry to stop is Ativan. It is habit-forming unlike antidepressants and after a few weeks, one develops tolerance and so you find that same dose is not working as well as before. One is then forced to increase the dose which works well for a few more weeks and then the same thing occurs. When one misses a dose or lowers it, there are withdrawal symptoms like tremors, emotional disturbance and anxiety. Regarding the gap between dosages, since Ativan is short acting, a thrice daily dosing would be more suitable. So split the morning dose into two and try taking 0.5 mg thrice daily. The usual treatment of anxiety or depression is with an antidepressant along with a benzodiazepine (like Ativan) in the beginning. After a few weeks, when the antidepressant starts working, the benzodiazepine is tapered off to prevent dependence. The patient is continued only on the antidepressant for around a year or more, depending on the disease severity and past history. Best wishes. Dr Preeti Parakh MD Psychiatry

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Brief Answer: Yes Detailed Answer: Hi, Yes, Cymbalta may work better for you since you found the others too activating. Just keep in mind that all anti-depressants may be associated with a slight increase in anxiety in the first few days. This gradually improves in a few days. In addition to the medicines, you will benefit if you can also regularly practice relaxation exercises like progressive muscular relaxation exercises or autogenic relaxation.These make a huge difference in anxiety levels. Detailed instructions are freely available online. I have included one such link for your convenience ( WWW.WWWW.WW au/docs/ACF3C8D.pdf). Best wishes. Dr Preeti Parakh MD Psychiatry

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Brief Answer: Explained below. Detailed Answer: Hi XXXXXXX It is not that Ativan is not working for you but the dose of Ativan that previously was sufficient for you, is not so anymore. The possible reasons are development of tolerance to Ativan or worsening of your anxiety disorder or both. Even spacing the doses has not been able to cover your symptoms and you would need a higher dose for better relief. I am not sure that Ativan is contributing to your gastritis because anxiety itself can worsen gastritis. If you taper off Ativan now, you will be left without any medicine to cover your anxiety. You have already tapered off Remeron and are also tapering off Paxil. In my opinion, your psychiatrist will prefer to start you on another anti-depressant like Cymbalta as we discussed or any other one and taper off Ativan after a few weeks when the antidepressant shows its response. I think you would also need a hike in the dose of Ativan to help you cope for the time being. If you would like to change Ativan, you can ask your doctor to prescribe any other benzodiazepine. I personally prefer to prescribe clonazepam (Klonopin) to my patients with anxiety as it is longer acting. Cross-tapering with longer acting benzodiazepines like diazepam is indeed the standard practice for managing withdrawal of Ativan. But it is required only in people who are dependent on it and take very high doses like 20 or 30 mg per day, where there is a high risk of seizures during withdrawal. You are on a very low dose of 1.5 mg per day and the usual practice for stopping this kind of dose is to just taper it off slowly. Best wishes. Dr Preeti Parakh MD Psychiatry

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Brief Answer: Yes, it is. Detailed Answer: Hi XXXXX! Yes, it is quite easy to switch to Klonopin from Ativan as both are very similar. You just have to keep in mind that around 0.5 mg of Klonopin is equivalent to 1 mg of Ativan. As you are presently taking 1.5 mg Ativan per day, around 0.75 mg Klonopin should be equivalent to it, though I feel you would need a slightly higher dose for complete relief of your symptoms due to tolerance. Klonopin is longer acting than Ativan and therefore, is effective in one to two times per day dosing. I personally prefer to prescribe it in two divided doses, keeping the morning dose lower than the night dose to avoid day time sedation. Best wishes. Dr Preeti Parakh MD Psychiatry

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Brief Answer: Good idea. Detailed Answer: Hi XXXXXXX It is great that your doctor had given you both options and I am sure he will have no qualms in agreeing to a switch. I hope you are soon started on a new anti-depressant which suits you better than the previous ones so that you no longer have to rely on only a benzodiazepine for relief. I also wish that you will take some time to try some of the relaxation exercises and see if they help you. I know of one patient who had panic attacks but was unable to tolerate any of the antidepressants. She was able to control her symptoms with just relaxation exercises without any medicines. There is no harm in giving it a try. If you find the muscular relaxation exercises too complicated or time-taking, just try taking slow and deep breaths when you are anxious. Even that makes a big difference. Best wishes. Dr Preeti Parakh MD Psychiatry

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Brief Answer: All the best! Detailed Answer: Hi XXXXXXX The breathing exercises and other relaxation exercises help in all kinds of anxiety disorders including PTSD. While doing breathing exercises, remember to take deep breaths very slowly, taking around double the time to exhale than to inhale. There are many other types of relaxation exercises as well and there is a lot of information on the internet. You can try any of them. PTSD is very disabling and I hope you soon find an antidepressant that suits you and is effective as well. I am sure Klonopin will help you in the meantime. If you ever need me again, I can be reached at WWW.WWWW.WW Best wishes. Dr Preeti Parakh MD Psychiatry

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Brief Answer: Good luck! Detailed Answer: Hi XXXXXXX You are always welcome! Take good care of yourself. Bad times have a thing in common with good times. Both of them are transient. I hope you get well soon and are able to lead a happy and healthy life. Best wishes. Dr Preeti Parakh MD Psychiatry

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