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Posted by: Footprints1973 Jul 1 2009, 09:31 PM

HI all,

I am new here an I have a question, I hope someone could share any experience they have...my general doc has been treating me for depression/anxiety for several years. I've been on a variety of the SSRIS and they all "poop out" after awhile.

Currently I am on Celexa 20 or 40 mgs, depending on my mood. However, for the past several weeks I've noticed my depression/axiety returning. And now I am having problems with insomnia--falling asleep.

My doc wants me to take 25 mg of Pamelor, a tricyclic before bed to help me sleep. I am scared because I read on line several places that this it is not recommended to combine these two classes of drugs because it can cause an increase in the amount of the tricyclic in your blood, or something to that effect.

My doc said it is a small dose so he says it should not be a problem. I should probably trust him, but me and my anxiety...

Has anyone here ever combined a SSRI with a small dose of a tricyclic like Pamleor or amitrypline, etc.? What happened..?


thanks so much
Laura

Posted by: Davevanza Jul 2 2009, 09:27 AM

I just want to share about my experience with SSRI/SNRI's and other antidepressants.

I had been long time on Imipramine and Amitriptyline, before my new psychiatrist changed me to PROZAC, then AROPAX ( Paroxetine, here in Australia ), ZOLOFT and CIPRAMIL. The reason he changed it because at those years, mid 1990's, SSRI's and SNRI ( Effexor ) were new, and almost every General Practitioner had some trial packs for the patients.

Along with the marketing involved, the Area Representatives of pharmaceutical companies were competing with each others, explaining the G.P ( Doctors ) that newer medications had fewer side effects. ( Well that's true, but again, everyone has different level of liver enzymes to break down these medications, and these enzymes are called Cytochrome P450, with subtypes ranging from 2D6, 3A4 etc....).

Combining SSRI's ( it depends on which one,too, CELEXA/CIPRAMIL-> citalopram is more selective compared to PROZAC,AROPAX/PAXIL), with Tricyclics ( it depends on which one, too, PAMELOR/ ALLEGRON in Australia, works more on inhibiting the re-uptake of Noradrenaline, than Serotonin, while ANAFRANIL->Clomipramine inhibits the re-uptake of Serotonin more than Noradrenaline), so, a small dose of CIPRAMIL in the morning along with a small dose of PAMELOR at nite, theoretically should not cause SEROTONIN SYNDROME, but so far, such a practice in Australia is not recommended, as some cases of SEROTONIN SYNDROME does happen, even under doctor's supervision.

Most medications in Australia is subsidised by the government, where that's not the case in USA. So, combining an expensive medication like CIPRAMIL with a less expensive older Tricyclic is being practised, for money sake.

Combination between CELEXA and PAMELOR will increase the amount of Nortriptyline ( Pamelor) in your blood system. Nortriptyline, being a metabolite o Amitriptyline, when our bodies get adjusted to its effect, some people find it rather activating, than sedating, thus making insomnia is a problem. The same thing also happens with Desipramine, being a metabolite of Imipramine, after awhile, some people find it activating, and insomnia can be a problem.

I am not a doctor. So it's better if you can talk about this matter to your doctor. ( I have an idea of why your doctor chooses Nortriptyline, a secondary amine, it can be because of it lacking in anticholinergic effect (dry mouth, constipation), compared to the Tertiary Amines, Amitriptyline.)

So far, i tried Amitriptyline and Nortriptyline, Imipramine and Desipramine.

For insomnia, 25mg to 50mg is enough to put me to sleep with Amitriptyline. To me, Nortriptyline causes insomnia, in long term, especially after my body get adjusted to its effect.

For Panic,anxiety and fear, Imipramine 10mg-25mg once or twice a day works better than other Tricyclics. Desipramine, to me, caused insomnia, agitation and a more pronounced irregular heart-beat, it does nothing for panic or anxiety.

So my advise is , talk to your doctor about this, as SSRI's could also cause insomnia ( it depends on which one, too, Fluvoxamine->LUVOX causes sedation, while Fluoxetine->PROZAC causes insomnia ).

Good luck and God bless you.

Posted by: whatsthefreakingpoint Jul 13 2009, 05:23 AM

Found your post while googling the same concern -- I'll make myself at least bookmark the monographs that come up on a search, but wikipedia.org is always better than it has any right to be with drug info. So far on my search I've found it to be common to mix SSRIs and tricyclics, apparently with an initial low dose of tricyclic regardless of which was the initial drug. The SSRI is likely to potentiate the tricyclic, but I'd expect the reverse as well. I don't think you're risking seratonin syndrome (though I don't know why) -- I think you're looking for enhanced or new side-effects, none of which are fatal nor irreversible. Mirtazapine isn't the tricyclic you're thinking of adding, but take a look at the wiki entry anyway -- it will probably make you feel much better about how routine this is. (They even mention Mirtazapine is used to COMBAT seratonin syndrome.)

I have had nearly zero luck with MDs -- I found a few who will take dictation from me and write for anything I'd like to pump into my brain (and liver) next; I don't know how common auto-experimentation is, but from my (nauseating) experience working in a mental hospital and with at-risk youth, I suspect it's non-existent. Institutionalized medicine will prescribe you their specific institutionalized drug and dose, because you will have been diagnosed with one of their three institutionalized "disorders" at intake, and luckily all three are candidates for the same drug and dose. You will know what you're in for at intake: look at the calendar, pens, wall clock, German luxury automobiles in the Dr.s parking lot -- your drug will be emblazoned on them all.

MDs in Private Practice probably have a slightly larger arsenal, but you're still getting advice on which oil to switch to, from a guy who will never see your engine, nor have any occasion to actually try ANY brand of oil, but if you're lucky he'll take your insurance. I've never met an MD (nor PhD nor MS for that matter) who has had any real first hand experience with anything remotely connected to depression, let alone medications; I firmly believe the sane can only diagnose sanity, so any professional advice will necessarily be coming from a child strategizing nutritional meals for his ants while occasionally glancing up at his ant farm 40 minutes a week (and, of course, charging the ants for the full hour.)
Found your post while googling the same concern -- I'll make myself at least bookmark the monographs that come up on a search, but wikipedia.org is always better than it has any right to be with drug info. So far on my search I've found it to be common to mix SSRIs and tricyclics, apparently with an initial low dose of tricyclic regardless of which was the initial drug.

I have had nearly zero luck with MDs -- I found a few who will take dictation from me and write for anything I'd like to pump into my brain (and liver) next; I don't know how common auto-experimentation is, but from my (nauseating) experience working in a mental hospital and with at-risk youth, I suspect it's non-existent. Institutionalized medicine will prescribe you their specific institutionalized drug and dose, because you will have been diagnosed with one of their three institutionalized "disorders" at intake, and luckily all three are candidates for the same drug and dose. You will know what you're in for at intake: look at the calendar, pens, wall clock, German luxury automobiles in the Dr.s parking lot -- your drug will be emblazoned on them all.

I've never met an MD (nor PhD nor MS for that matter) who has had any real first hand experience with anything remotely connected to depression, let alone medications; I firmly believe the sane can only diagnose sanity, so any professional advice will necessarily be coming from a child strategizing nutritional meals for his ants while occasionally glancing up at his ant farm 40 minutes a week (and, of course, charging the ants for the full hour.)

Then again, I'm now on near-fatal doses of three drugs, and I'm sold on starting a fourth tomorrow. Either I have a relatively high tolerance or I've actually been dead the past few years without anyone bothering to mentioning it (which would in itself account for the depression, I suppose...) When I stumbled up to my therapeutic threshold, it was a pronounced, binary effect. I did not sneak up on it. It was seeing the sun for the first time, immediately followed by a rush of cosmic realizations ("b. this is how "normal" people feel; c. this is why they don't dread contact with anyone and everything; d. so my job probably does suck, but not nearly to the degree I'd experienced before ever having seen sunlight...) These drugs and doses might well **** me or grow me another head on a stalk pushing through my naval, but I don't care -- I'm not going back to the unending s*** that was Life. So... I'm not likely to give careful, considered advice ("just start taking pills at random -- clean out friends' medicine cabinets at parties or on weekends they're away -- worked for me!")

BUT... you've got buttons and dials and meters and flashing lights you're probably not entirely aware of, that no one else could possibly know or understand. I think meditation, yoga, BIOFEEDBACK, ***NEUROFEEDBACK***, etc are good supplements to traditional "therapy" (read: lots and lots of drugs) but much more importantly they get you more in tune with your specific machinery. If you rub this snake oil on your head every 10 minutes, I can tell pretty objectively if it helps you grow hair. Or get taller. Or richer. You are the only one you're likely to meet who will have any understanding of what actual effect endogenous and exogenous chemistry is having on you where it matters. The only relevant question I could think of to ask an MD you already covered here: "Is this less than 70% likely to **** me?" Stay away from new drugs (Abilify paralyzed my tongue for a week, which I found particularly depressing, and Chantix almost made me a Bush supporter) and move slowly and conservatively, but know you can move in unorthodox ways. I believe there's a perfect cocktail for you, and I believe you have roughly no chance of finding it. But I KNOW you can come pretty D*** close.

Then again, I'm now on near-fatal doses of three drugs, and I'm sold on starting a fourth tomorrow. Either I have a relatively high tolerance or I've actually been dead the past few years without anyone bothering to mentioning it (which would in itself account for the depression, I suppose...) When I stumbled up to my therapeutic threshold, it was a pronounced, binary effect. I did not sneak up on it. It was seeing the sun for the first time, immediately followed by a rush of cosmic realizations ("b. this is how "normal" people feel; c. this is why they don't dread contact with anyone and everything; d. so my job probably does suck, but not nearly to the degree I'd experienced before ever having seen sunlight...) These drugs and doses might well **** me or grow me another head on a stalk pushing through my naval, but I don't care -- I'm not going back to the unending s*** that was Life. So... I'm not likely to give careful, considered advice ("just start taking pills at random -- clean out friends' medicine cabinets at parties or on weekends they're away -- worked for me!")

BUT... you've got buttons and dials and meters and flashing lights you're probably not entirely aware of, that no one else could possibly know or understand. I think meditation, yoga, BIOFEEDBACK, ***NEUROFEEDBACK***, etc are good supplements to traditional "therapy" (read: lots and lots of drugs) but much more importantly they get you more in tune with your specific machinery. If you rub this snake oil on your head every 10 minutes, I can tell pretty objectively if it helps you grow hair. Or get taller. Or richer. You are the only one you're likely to meet who will have any understanding of what actual effect endogenous and exogenous chemistry is having on you where it matters. The only relevant question I could think of to ask an MD you already covered here: "Is this less than 70% likely to **** me?" Stay away from new drugs (Abilify paralyzed my tongue for a week, which I found particularly depressing, and Chantix almost made me a Bush supporter) and move slowly and conservatively, but know you can move in unorthodox ways. I believe there's a perfect cocktail for you, and I believe you have roughly no chance of finding it. But I KNOW you can come pretty D*** close.

Posted by: whatsthefreakingpoint Jul 13 2009, 05:39 AM

After all that, I still haven't actually answered on point: while discontinuing amitriptyline and reintroducing bupropion and sertraline (and provigil, because I could) there was a point during the crossover where I felt pretty close to how my ideal cocktail put me (I can't afford my ideal cocktail, by the way, thus the continued experimentation. That, and boredom.) Having lost another fight with my insurance company re generics versus brands that actually include the active ingredient, I thought about trying to safely reproduce this chemical crossover. Ideally I'd like a free range of Mirtazapine to play with and start with a negligibly small dose, but my insurance will only cover the lowest dose. I've still got some amitriptyline 150mgs around, which cut up nicely into 75mgs, but become powder upon subsequent cutting attempts. Like you, I wondered if 75mgs would be safe after having dc'd it 6 months ago, with a good amount of the other stuff firmly in my system. Unlike you, I simply decided it is perfectly safe, and so far I haven't died, to the best of my knowledge. If I see my life flashing in front of me, I'll try to post my imminent death here as an addendum, but I think it's unlikely, so I think it's very unlikely you'll experience anything profoundly negative, and I'm hoping you'll be pleasantly surprised not just with sleep but during the day as well.