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Dr. Andrew Rynne

Family Physician

Exp 50 years

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Suggest treatment for phobia,anxiety and depression

Answered by
Dr.
Dr. Vipul Prajapati

Psychiatrist

Practicing since :2009

Answered : 850 Questions

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Posted on Wed, 27 Aug 2014 in Mental Health
Question: Respected Sir,
I had consulted some psychiatrists but the treatment was discontineud
for some reasons.I wish that I should be given freedom for full expression of
what I want to say and treatment be decided accordingly.
For following reasons the treatment was left.
Some drugs caused constipation,some caused daytime sedation.
Some caused involuntary bowel movement.some caused excessive dryness
of mouth.Some caused rebound anxiety and hangover / blank feeling.
Small quantity of stools pass out with the gas/flatus with some drugs.
I have phobic and generalized anxiety and depression.There are speech
communication problems since childhood.
There is great lethargy / inertia,forgetfulness / memory problems,concentration
problems and impatience.Weakness is experienced especially in the evening
for no obvious and physical reasons.
I am 48 years old,doing a clerical sedentary job in a bank.I am health literate
and have some literacy of psychiatry.
Venlafaxine,Duloxetine caused constipation.Bupropion and Flouxetine also
constipation.But they also caused involuntary bowel movement.
I donot want drugs that
1.cause constipation
2.cause looseness of bowels / involuntary passage of stools
with/without flatus.
3.cause rebound anxiety and hangover
4.cause uncontrollable daytime sedation
I wish to have best posssible drugs combination as per my requirements.
I want to take advantage of all available medicines.
My experience with nitrazepam/ alprazolam/ clonazepam is very favourable.
It is for short time of about 5-6 hours.But these cause rebound anxiety which is
more painfull.
I was on paroxitine and I was feeling good.I had to leave this medicine as
sometimes caused stools passage with gas/ involuntary stool passage.
Now there are other antidepressants left—citalopram,escitalopram,
tinepline,fluoxamine etc.
Another category is smaller doses of olanzapine or resperidone.There are
also medicines in the category of haloperidol and thioridazine in lower doses,
We have anti-anxiety drugs –buspirone and flupenthixol,hydroxyzine.
We also have piracetam for memory and anti-epileptic / anti convulsant drugs,
melatonin etc.There are many other drugs.
Most useful yet flexible combination considering drugs interactions is
necessary for me.I am not in favour of over-usage of drugs.But if the drugs
are useful and indicated I would like to avail their fullest benefit.
If I am put on olanzapine on regular basis,is it possible to take
clonazepam on regular / sos basis.Which anti deppressant may be taken
with these.Is it possible to add flupenthixol and buspirone.
Occationally if sedation at night is necessary,which medicine may be
taken SOS.Whether trazodone/mirtazapine-sos will do for sleep.
Whether piracetam / similar drug can be helpful for memory problems.
Whether hydroxizine-sos can be used for stressfull situation or sedation.
Which of the anti epileptic/anti-convulsant drug/s is benificial.
What are other useful medicines.
Let me have various compatible combinations with alternatives for best
optimum results.I want to take treatment seriously,sincerely and regularly
without discontinuation.I am in need ot treatment and wish to lead normal
happy life.
Please let me have such drug treatment plan / regimen with necessary
alternatives / options,with all relevant information / instructions / clarifications.
I will provide any other required information.I may also be given access to
to contact you for any difficulty/problem in a XXXXXXX and free manner.
I may be required to have one or two more communications before
finalizing treatment.
doctor
Answered by Dr. Vipul Prajapati 4 hours later
Brief Answer:
consult psychiatrist

Detailed Answer:
Hi dear,

Thank you for your query.

As you told you have phobia, GAD, and Depression and you tried many medication but you have many side effects and which is not tolerable.
I want to know in what dose you have taken medicine and experienced side effects.

i would preferred Desvenlaflexine medication in your case as it has very less side effects and useful both in anxiety and depression.

clonazepam , alprazolam can be taken regular basis and sos basis but as prescribed by psychiatrist because they have property of addiction.
but there is medication now a days available which do not have a sedative property like Etizolam and tofisopam.
you can discuss with your doctor bout this medication.

memory problem is one of the symptom of depression and not a different entity so when your depression is relieved memory problem also goes away so not to worry about memory. it is called pseudo dementia.

i advised you not to use steroids like hydrocortisone for stress.
mirtazepine and trazodone drug should not be taken as sos basis if you take it sos basis it has not full effect.

as you give history regarding medication but not about your illness.
so please give detail history .

consult psychiatrist for detail history and mental status examination and discuss .

Awaiting your response.

Thank you


Above answer was peer-reviewed by : Dr. Raju A.T
doctor
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Follow up: Dr. Vipul Prajapati 14 hours later
Thanks a lot .I am writing to you further shortly before closure period.
love n gratitude.
doctor
Answered by Dr. Vipul Prajapati 12 minutes later
Brief Answer:
consult psychiatrist.

Detailed Answer:
Hi Dear,

Thank you.

waiting for your response..

Dr. Vipul Prajapati
Above answer was peer-reviewed by : Dr. Raju A.T
doctor
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Follow up: Dr. Vipul Prajapati 34 hours later
Please accept my deepest gratitude for your kind reply and advice.
I give below history of my previous prescriptions for last 3-4 years.
These were stopped for reasons mentioned earlier.
1..cap duzela 40 hs + cap gabantin 300 hs + tab etirest .5 sos

2..tab lamez 100 od + tab fostera 5 od + tab zupion sr 150 od

3..tab paroxitine 10 od + tab clonazepam .25 od
Considering that I shall take desvanlafaxine and tofisopam/etizolam
I request most sincerely and humbly for considering following points.
I am in favour of taking full advantage of all available medicines
useful and applicable to me for leading normal life.I cannot bear
constipation caused by drugs and involuntary stool slippage.
1..whether some drug from antipsychotics group can be added
like olanzapine 2.5 etc
2..whether some drug from ant convulsant/anti epileptics group
can be added.
3.please suggest a sedative for sedation at night on sos basis.I
sometimes require it.
4.please advise one more alternative antideppresant like desvanlafaxine.
Antideppresants had unexpectedly and unpredictably caused constipation
to me.
5.. Any other addition and instructions may please be advised.
6.Please advise suitable dosage or dosage range for all drugs considering
my condition as moderate to severe.
I once again request for your kind full fledged guidance and reply.
with love,regards n gratitude.
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Follow up: Dr. Vipul Prajapati 4 minutes later
Please accept my deepest gratitude for your kind reply and advice.
I give below history of my previous prescriptions for last 3-4 years.
These were stopped for reasons mentioned earlier.
1..cap duzela 40 hs + cap gabantin 300 hs + tab etirest .5 sos

2..tab lamez 100 od + tab fostera 5 od + tab zupion sr 150 od

3..tab paroxitine 10 od + tab clonazepam .25 od
Considering that I shall take desvanlafaxine and tofisopam/etizolam
I request most sincerely and humbly for considering following points.
I am in favour of taking full advantage of all available medicines
useful and applicable to me for leading normal life.I cannot bear
constipation caused by drugs and involuntary stool slippage.
1..whether some drug from antipsychotics group can be added
like olanzapine 2.5 etc
2..whether some drug from ant convulsant/anti epileptics group
can be added.
3.please suggest a sedative for sedation at night on sos basis.I
sometimes require it.
4.please advise one more alternative antideppresant like desvanlafaxine.
Antideppresants had unexpectedly and unpredictably caused constipation
to me.
5.. Any other addition and instructions may please be advised.
6.Please advise suitable dosage or dosage range for all drugs considering
my condition as moderate to severe.
doctor
Answered by Dr. Vipul Prajapati 2 hours later
Brief Answer:
consult psychiatrist

Detailed Answer:
Hi dear,
we can add drug from anti psychotic group if we not get proper response from anti depressant full effective dose for minimum effective period.
we can augment anti depressant effect by adding anti psychotic like aripiparazole, olanzapine, quitiapine etc...
we can also augment with mood stabilizer or anti convulsion drugs like lithium, sodium valproate, thyroid hormones, etc...
for sedation in night you can try lorazepam 2mg on sos basis only after you informed your treating doctor.
other drug like desvenlaflaxine we can try newer molecule like agomelatine, tianeptine, sertraline, also combination of escitalopram and l-methayalfolate , etc...
desvenlaflexine in dose of 50 to 100mg but go up to 200mg also , agomelatine 25 to 50 mg , tianeptine in 37.5mg dose, sertraline up to 200mg can be taken .
all such medication taken after discussion with your treating doctor.
other instruction like do exercise regularly and take medication regularly.
do investigation of thyroid profile.

not to worry about side effects as this all are having fewer side effects.

Awaiting your response.

Thank you
Above answer was peer-reviewed by : Dr. Prasad
doctor
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Follow up: Dr. Vipul Prajapati 2 days later
Thanks once again.
Treatment to begin with for a month or two would be
1..desvanlafaxine 50 od OR agolamelatine 25 od AND
2..tofisopam od OR etizolam od AND
3..olanzapine 2.5 od AND
4..lorazepam 2 sos hs
Follow up and review of treatment after one or two months.
Addition of mood stabilizer/elevators from anti epileptic/anticonvulsant
group to considered after 2-3 months.
As I had mentioned in stressful situations and fearful interactions I used
to take clonazepam .25 sos. Now instead please advise what I should
take in such conditions.whether tofisopam/etizolam additionally sos will do.

Please arrange to make suitable changes in above plan.
Please advise dosage for tofisopam and etizolam.
Please advise available brand/trade names.
Please edit the dosage above if necessary and advise time for above,morning,night etc.Necessary editing may please also be done
in view of drug drug interactions.What if denvanlafaxine is replaced
by tianeptine/sertraline/escitalopram.whether other drugs mentioned above
would be compatible.
I thank you once again for your very useful advice.My regards and
gratitude to you and best wishes to you and members of your family.
Awaiting your kind reply with blessings and intuitive suggestions.
Love.

doctor
Answered by Dr. Vipul Prajapati 9 hours later
Brief Answer:
discuss with psychiatrist

Detailed Answer:
Hi dear,

For a stressful situation and fearful interaction you can take Clonazepam 0.25mg or Etizolam 0.5mg mouth dissolving tablet.

What ever you and your psychiatrist decide is good plan and go for it. Just continue Desvenlaflexine instead of Agomelatine.

For Tofisopam is available in 50 and 100 mg strength and dose is 50mg three times a day and maximum 200mg.

For Etizolam is available in 0.25 mg, 0.5 mg and sustained release 1.5 mg strength. Dose is depend on your anxiety and given for three times a day.

Brand names for Tofisopam is only one Toficalm, for Eetizolam is etizola, etirest, etilam, ELM cr etc.. For Desvenlaflexine is Prestiq, MDD XR, D-veniz, Zyven od etc..

Desvenlaflexine you can take at any time and for Olanzepine, Agomelatine, Lorazepam should be take in night.

You can use all the drugs with Etizola, Tofisopam, Lorazepam, Olanezepine, so not to worry about drug interaction.

Discuss with your treating doctor.

Thank you
Above answer was peer-reviewed by : Dr. Ashwin Bhandari
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