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    How to treat agoraphobia while on Klonopin and Risperdal?

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Posted on Thu, 10 Aug 2017 in Mental Health
Question: i have a long history of panic disorder with agouraphobia. I've been a prozac for 20 years with mostly good years and a few relapses. Each relapse has been treated in roughtly the same way. Double the prozac, add something to sleep, usually trazodone, a short 3 to 4 month course of a benzo and therapy. For the past 7 years I've lived a fun filled panic free life until a majoy relapse 3 months ago. GP sends me to find a psychiatrist and a therapist. Psychiatrist prescribes ambien cr for sleep and 1 mg. of klonopin per day but does nothing to the prozac. (confused me). GP follow up and he says go back and tell him to do something about the antidepressant. "Prozac can cause anxiety, find something less agitatin" (even though ('ve been on it 20 years and am long past side effects) The psychiatrist prescribe celexa. Cross tapper for a week 10 mg of celexa each day, prozac every other day.. week 2 to 4 20 mg. Side efffects sweating, clenched teeth, higher anxiety, anxiety attacks leading to more avoidance. 4 week folllow up and the psychiatrist concerned about the panic attacks added Effexxor 75xr, and Risperdal .25. The pharmacist was the 1st tos show concern about combining the ssri with the snri together. This was not a switch they were to be used together. A doctor on this site also expresses concern so I sought out a 2nd opinion at the center where I go for thereapy and met with their psychiatrist. He llistened to the story a replied "You have too many cooks in the kitchen,, I would never tell your GP what to prescribe for your bllood pressure. And agreed that there was no reason for the risperdal and effexor so soon on the celexa treatment. What he decided to do was raise the celexa dose to 40mg. Which brings my to my questions.
I've now been on the celexa 8 and a half weeks. One week at 10mg. 5 weeks at 20, and 2 and a half at 40. I've seen no major reslults in terms anxiety relief and my avoidance and agouraphobia is high. When I saw him this week he wants to give the celexa 3 more weeks at this dosage. He also hinted at possibly changing back to prozac if thins don't improve.. My concern how isolating I am becoming and the fact that I have to be ready to teach school in 4 weeks. The idea of going through the start up side effects of a new antidressant at the start of a school year frightens me. i have made an appointment to speak with him this week about 2 things. to explain mt concerns and to ask about the possibility of doing the Genesight genetic testing they offer to guide selection the right meds. Have you used the gegnetictesting? Do you think it's a good idea to give the celexa more time? How hare would it be to teach
school wjhile beginning a new antidepressant with alll th stimulation that comes with it?
doctor
Answered by Dr. Ashok Kumar 50 minutes later
Brief Answer:
I think it is time to go back for prozac

Detailed Answer:
Hello,
Thanks for using Healthcaremagic.

I read your query and understand your concerns.

First of all I agree with the comment of your psychiatrist that there are too many cooks in your kitchen and everybody claims to be superior to others.

Now regarding the next course of action I feel moving back to the old guard should be the preferred choice. As you know that prozac helped you for 20 years and on every occasion a slight increase in dose helped you completely.

I understand it causes increased anxiety (as reported by your gp) but the increased anxiety is limited to initial two weeks of starting or dose change and rarely afterwards.

My opinion is based on the fact that 20 mg of celexa (which is effective dose range) is almost there for one and half months and 40 mg (maximum dose) is there for last two and half weeks, at which the effective medicine shows its effects to the great extent. I do not mean that celexa will not work but the possibility of prozac doing needful is much higher than celexa.

I also feel that during cross titration a benzodiazepines can be used in slightly higher dose in compare to past. It could be clonopin 0.5 to 2 mg on need basis.


Regarding the genetic testing I understand that it is promising but still inconclusive results are available. I also acknowledge that the facility is not available here in XXXXXXX and I have never had a chance to use it for drug selection.

I hope this answers you.
Feel free to write back to me if you have more questions.
Thanks and regards.
Above answer was peer-reviewed by : Dr. Vaishalee Punj
doctor
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Follow up: Dr. Ashok Kumar 7 hours later
In what manner would you suggest the switch?
doctor
Answered by Dr. Ashok Kumar 9 hours later
Brief Answer:
By cross titration

Detailed Answer:
Hello,
Thanks for follow up.

Considering the current dose of 40 mg celexa and just four weeks remaining before starting schools I will recommend slightly faster but useful titration.

Week 1
Celexa 30 mg

Week 2
Celexa 20 mg and prozac 20 mg

Week 3

Clexa 10 mg and prozac 20 mg

Week 4

Celexa stop and prozac 40 mg

As you might be knowing that there is slight but definite risk of serotonin syndrome while combining two SSRI so it is important to report every symptom to your doctor specially related to serotonin syndrome.

In addition as suggested take clonazepam on need basis as recommended by your current psychiatrist.

I hope this helps you further.
If you have any further query, I would be glad to help you.
If not, you may close the discussion and if possible you may rate the answer for my future patients.
In future if you wish to contact me directly, you can use the below mentioned link:
http://doctor.healthcaremagic.com/doctors/dr-ashok-kumar/67386
Thanks and regards.

Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar
doctor
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Follow up: Dr. Ashok Kumar 13 hours later
That seems like a rather quick increase in the prozac. The day this relapse began I took 40 mg. and had heart palpitations. Will never know if it was the drug or my anxiety.

Can you think of any other medication that might be effective?
doctor
Answered by Dr. Ashok Kumar 13 minutes later
Brief Answer:
TCA can be used

Detailed Answer:
Hello,
Thanks for follow up.

I agree that it was slightly rapid increase but considering the availability of just 4 weeks we can do it in almost rationale manner.

In case you are not willing to take such rapid increase ask your doctor to explore TCA as replacement to SSRI group of medications. TCAs are older antidepressants with better efficacy but with cost of increased side effects.

At 55 years of age I often prefer nortryptiline or desipramine as they have relatively low chance of side effects in compare to other TCA medications.

I hope this helps you further.
Thanks and regards.
Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar
doctor
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Follow up: Dr. Ashok Kumar 12 minutes later
Thank you for your quick response. I will discuss all options with psychiatrist.
doctor
Answered by Dr. Ashok Kumar 34 minutes later
Brief Answer:
You are always welcome

Detailed Answer:
Thanks you very much for your valuable feedback.

I am glad to know that the information was useful to you and you will discuss same with your psychiatrist.

Since this is the last follow up you are allowed for the current question I request you to open a new thread if there are more questions.

While posting another query please use my url which is as follows. This will ensure direct delivery of your question to me and continuity of care.

http://doctor.healthcaremagic.com/doctors/dr-ashok-kumar/67386

Thanks and regards.
Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar
doctor
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Follow up: Dr. Ashok Kumar 34 hours later
Thank you so much for your advice. I will probably get a few other opinions as well.
doctor
Answered by Dr. Ashok Kumar 2 hours later
Brief Answer:
I agree

Detailed Answer:
Hello,
Thanks for follow up and great feedback.

I completely agree that with available more experts (online as well as in person) we have more choices. Fortunately the suggestions come from individuals with experience in different settings in the same specialty which adds value.

I am more than sure that you will achieve desired results in regard to your health.

Wish you best health ahead.

Thanks again.
Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar
doctor
Answered by
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Dr. Ashok Kumar

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Practicing since :2000

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