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Dr. Bob is Robert Hsiung, MD,
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Posted by Alan on October 11, 2002, at 22:40:56
In reply to Re: benz. / vs SSRI's...see bottom » Alan, posted by pharmrep on October 11, 2002, at 20:03:20
> ** well alan...i got you some face time today...i got the chance to ask 4 doctors how they felt about benz, and why benz. are not used as much as ssri's....i got similar and varied answers, but here are the commonalities.
> ---feelings on why benz. are not used as much__
> 1) habit forming
> 2) short acting
> 3) the anxiety may be treated, but it may leave the depression even worse...there are some (not all) ssri's that can treat both depression and anxiety.
>
> PS If an SSRI like Celexa or Lexapro can reduce a persons score on...lets say the madres scale from 26 (major depression)...by 50% to 13..(mild depression), and also the inner tension items (anxiety subscale), I wouldnt call that "little improvement".
================================================Thank you for addressing my question pharmrep.
What I am about to say is not directed specifically to you but is commentary on the content of the answers provided by your sample of 4 selected doctors.
Bzds vs AD's for anxiety disorders:
1)Habit forming?
What specifically is meant? That those with chronic anxiety disorders develop "medical dependence" on a medicine designed to treat a medical condition? (Or do the 4 doctors even make a distinction between addiction and medical dependence?)
Or that there is a typical dependence/withdrawl cycle as now commonly seen in many new AD's, euphemistically referred to as "discontinuation syndrome". Or tolerance similarly referred to as AD "poop-out" (not to mention dosage escalation to treat patients when they do "poop-out")?
As long as doctors are pushing an SSRI at every patient who even looks at them cross-eyed, there's not going to be any opportunity to observe drug-seeking behavior associated with "habit forming" (just another euphemism for medical dependence). In fact, what they see right now is SSRI-avoidant behavior.
But let the doctors start withholding SSRIs and doing all they can to get people off of them (a day that may well come), and then we will see drug-seeking behavior from people who might even prefer to be off but can't even possibly quit over the two week period now recommended as a taper (it took a good long time for there to be an admission that AD's needed to be tapered in the first place, remember?).
2) short acting?
How is keeping up with one or two or three doses of a bzd that much different than taking a once a day AD? Half-life isn't an issue that I know of if bzd's are managed and prescribed properly...at least no less important than keeping up with their dosage regime of an AD.
Or are you talking about short acting in the sense that they are supposedly not meant to be taken for longer than let's say 3 - 4 weeks at a time? That myth was long ago disproven by the "Report on the Rational Use of Benzodiazapines" issued by the World Heath Organisation (independent and hardly a heavily pharmecutically sponsored organisation) that considered 40+ years of studies concluding that short AND long term use of bzds in the treatment of anxiety disorders is not only highly effective but very safe for the general population. The typical panic population does NOT report escalating dosages but rather a level that generally stays the same or DEcreases over time.
3)Huh? I thought the issue was anxiety disorder. Taking away anxiety with a bzd with the result being residual, exacerbated depression shows that the individual doesn't have an anxiety disorder to begin with but has the ubiquitous "mixed anx/depress" dx commonly used when the less skilled clinician (usually the front line physicians like GP's or internists whom these new AD's are the company's largest market by far) can not or are incapable of teasing out which is primary and which is secondary in order to treat effectively...The only known and relatively uncommon side effect of any bzd and depression that I've read about or know of is with klonopin...and decreasing the klon dosage while augmenting with xanax or ativan is the standard antidote and treatment protocol whenever this occurs.
As a matter of fact, there are studies that conclusively prove that xanax has a mild antidepressant effect - probably because it relieves relentless, hopeless depression ABOUT the anxiety...
Which leads to the PS. part.
How are clinicians going to decipher if the relentless anxiety is what is primary - driving the hopelessness of depression, if an AD is going to stimulate and sedate (to use the crudest of layman terms) at the same time? Does this scale take into account whether or not there was any augmentation with a bzd?
As a veteran of 6 AD's that did just that, never treating my anxiety disorder because of the pushing of the AD as the superior and therfore first line of treatment of anxiety disorder, and similar stories from a sizable population on this board and others that have to end up taking a bzd in the end with their AD anyway, and with efficacy rates at very best 40 - 50% by any company's own accounts, perhaps the 4 doctors can answer one key question.
Why aren't bzd's with efficacy rates in the 70 -80 percentile being offered on an equal footing with the new AD's (post 1992) in the treatment of anxiety disorders?
Curious,
Alan
Posted by ZeeZee on October 11, 2002, at 23:05:14
In reply to Re: AD's vs. Bzds for Anxiety disorders - Alan » johnj, posted by Alan on October 11, 2002, at 19:06:10
Alan-
I thoroughly enjoy reading your posts and have found them very helpful. I'm comforted in knowing there is a "champion" here for those of us with anxiety disorders. However, I must disagree with your advice to johnj in regard to how to decide whether anxiety or depression is the primary disorder. My primary and only diagnosis is panic disorder with agoraphobia. Although I agree with you that the AD's have been horribly disappointing for me and many like me (making my panic millions times worse) the MAOI's Nardil and Parnate were the exception and Godsends. You mentioned that if an AD works for your anxiety then maybe it's primary depression driving the anxiety. Both Nardil and Parnate eliminated my panic, anticipatory anxiety, OCD type thoughts, and greatly reduced my phobic avoidance. I was not and am not suffering from depression. I wish I could take Parnate again (Nardil has too many side effects) but unlike my success in the past, I recently had intolerable side effects and could not continue with it.
I do agree that the "currently" prescribed AD's (primarily the SSRI's) do little to help those of us with anxiety disorders and instead make our symptoms worse, with intolerable side effects on top of it all. There are many posts confirming this sad fact as I read about the new Lexapro users reporting "still feeling anxious", or "agitated", or "no longer depressed but more anxious." It's also discouraging to read so much on this site quoting research in support of the use of AD's for depression but little in regard to its efficacy with anxiety.
Yes, I do use Xanax and Klonopin, as needed. However, the effects of these drugs will never compare to the sublime state of "normalcy" found with the use of Parnate.
Just wanted to share my experience and personal opinion since johnj is looking for answers.
Posted by Alan on October 11, 2002, at 23:21:59
In reply to Re: AD's vs. Bzds for Anxiety disorders - Alan, posted by ZeeZee on October 11, 2002, at 23:05:14
Well stated and appreciated! I know of many success stories with the MAOI's in combo with xanax, etc and was on one track with the AD vs. bzd's - this probably considering all of the "face time" we are seeming to be getting free of charge via-a-vis AD's and anxiety disorders (completely unethical no matter how well intended or how one couches it - they're professional salesman after all - but that's just my opinion of course.)
MAOI's and bzd's have indeed saved one of my best friend's and colleague's career and life!
Best to you,
Alan
Posted by ZeeZee on October 12, 2002, at 9:17:32
In reply to Re: AD's vs. Bzds for Anxiety disorders - Alan » ZeeZee, posted by Alan on October 11, 2002, at 23:21:59
I totally agree with you in where you're coming from in regard to the professional salesperson. I have expressed myself before in this regard however have received no support for my position, which is in fact the same as yours. Lest we receive continuous PBC's or ban's our point unfortunately cannot be taken further.
This is LLL.
Posted by BrittPark on October 12, 2002, at 12:44:50
In reply to Re: Lexapro or eqiv. vs. Bzds for anxiety disorder » pharmrep, posted by Alan on October 11, 2002, at 22:40:56
Here, Here. Benzophobia is as common in the treatment of anxiety as Opiophobia is in treating pain. People with chronic anxiety or pain are grossly undertreated in the US.
Britt
Posted by Alan on October 12, 2002, at 13:37:42
In reply to Re: Lexapro or eqiv. vs. Bzds for anxiety disorder » Alan, posted by BrittPark on October 12, 2002, at 12:44:50
> Here, Here. Benzophobia is as common in the treatment of anxiety as Opiophobia is in treating pain. People with chronic anxiety or pain are grossly undertreated in the US.
>
> Britt
========================================
Well said Britt.
For me it is a matter of commercialism and economics trumping patients being trusted for what they have to say by their sometimes paternalistic doctors (of any stripe). This is of course not always the case - but one reads so much about this very thing on this bboard and many others.It is, I suspect also deeply rooted culturally speaking when it comes to the dreaded and misunderstood "A" word (addiction) which of course has nothing whatsoever to do with medical dependence...but the pushing of AD's for anxiety by pharmecuticals exploit those fears with the "non-habit forming" tease.
Now look at these bboards talking about withdrawing from AD's. Or the Paxil lawsuit about co.'s so emboldened to withold these symptoms because they can throw out so many test results and cherry pick the ones (after they change the testing criteria) that they send to the FDA for approval. Shame on the FDA. Ever had a doc look at you with a blank stare when you tell them about the withdrawl (sorry, "discontinuation syndrome") that you feel going off an AD simply because it's not listed on the package insert???
How many times did I personally see many top doctors who would not acknowledge what I was telling them about my anxiety (after I complied with all of their "wait the side effect out" suggestions) to have to end up firing them while at the same time having my career and relationships remain in jeopardy to fit "their" commercially and ideological agenda?
I did this for years, waiting out this and that and the other thing while not getting sufficient treatment. I can see why those that are not offered ALL of the options of treatment with REALISTIC risk-assessment just go through life thinking that this is just the best psychiatry can do for me....
I even found myself early on weighing the cost/benefits of having symptom relief at the expense of my sexual life (a side effect of AD's WAY under reported by the way)! Now how absurd is that kind of rationale to heap upon an already suffering patient? How much harm can be done by creating that kind of emotional conflict. This isn't to say that it happens to everyone....but a large population seems to be right here on the internet talking about these very same issues...in a virtual "world" group therapy.
Why did it take me and many others that I read about on this list so long to find a doctor that listened to what was being told to them?
The terrific pdoc that I eventually ended up with is well known in a large metropolitan area, heads an entire psy dept, and is highly regarded by their peers. Why did I have to wait years for someone like them to say right off the bat during the first visit, after previously reviewing unsuccessful clinical trials galore with every drug under the sun - EXCEPT those evil bzds in MONOTHERAPY), "Well, which drug do you feel better taking?"
That's all I needed to hear.
I know I share this experience with many others...if they only knew what was actually happening to them. It's all about giving or taking away a patient's right to choose their own destiny and form of treatment. Except in the most extreme of cases (institutionalisation issues and the like), the patient is the boss and the doc is the employee.
And that's a hard lesson to learn - if one is ever fortunate to be in the position to learn it at all.
Sorry for the rant.
Alan
Posted by Dinah on October 12, 2002, at 14:29:45
In reply to Re: Lexapro or eqiv. vs. Bzds for anxiety disorder » BrittPark, posted by Alan on October 12, 2002, at 13:37:42
Posted by Geezer on October 12, 2002, at 15:01:33
In reply to Re: Lexapro or eqiv. vs. Bzds for anxiety disorder » BrittPark, posted by Alan on October 12, 2002, at 13:37:42
Alan,
IMHO, no need to apologize....one of the best "rants" I have read in a long time. If we were talking Cardiac Surgery I would offer a humble bow to the surgeon for his training and experience, in Psychiatry (where nothing is known with certainty) the "consumer's" anecdotal experience seems to be most valuable. As you mention - the reasons are diverse and anything but medical.
Good cheer
Posted by GabbiX2 on October 12, 2002, at 15:15:36
In reply to Re: Amen! (nm) » Alan, posted by Dinah on October 12, 2002, at 14:29:45
I'm printing that and bringing it to my Dr.
He's refusing to re-prescribe Benzo's though they've worked for me before, and anxiety is ravaging my personal life (whats left of it)
which of course compounds the anxiety.Thank-you
Posted by Alan on October 12, 2002, at 15:45:11
In reply to Re: Amen! Alan ThankYOU, posted by GabbiX2 on October 12, 2002, at 15:15:36
> I'm printing that and bringing it to my Dr.
> He's refusing to re-prescribe Benzo's though they've worked for me before, and anxiety is ravaging my personal life (whats left of it)
> which of course compounds the anxiety.
>
> Thank-you
============================================While you're at it you may want to take this in too:
http://panicdisorder.about.com/library/weekly/aa031997.htm
Also ask them if they've taken the time to read the World Health Organisation's report on "The Rational Use of Benzodiazapines" (or at least the summary thereof) which uneqivocably states that short AND long term use of bzd monotherapy is some of the safest psychotropic medication in existence for the general population when treating symptoms of anxiety disorder.
If they look at you dead-pan or refuse to accept these basic fundamental concepts, perhaps taking control of your life and finding a doc that acknowledges these simple to understand ideas is the best route to go.
How to do that....that's a whole other thread I'm afraid. There is a catch 22 involved in "doc shopping" for these meds - totally unfair to the patient I might add.
A treasured member here at babble, Faschad, posted about this a few months back - perhaps you can find it in the archives...or I can find it later...or someone else knows where it is. "The controlled Substance Catch 22" was the title I believe although it was in another thread title...
Regards,
Alan
Posted by Micki on October 12, 2002, at 16:26:05
In reply to Re: Amen! Alan ThankYOU » GabbiX2, posted by Alan on October 12, 2002, at 15:45:11
This is my 6th day on 10 mg Lexapro and I feel just as anxious and depressed, and more lethargic than before. Could barely force myself to go to the grocery store today, and can't seem to bring myself to wash the dishes in my sink. Does this mean this is the wrong drug for me, or might this still turn around...I know 6 days isn't very long.
Picked up the second prescription my doctor called in for me--Seroquel, which is an anti-psychotic, but she said to take it in a low dose (12.5 - 25 mg) and it may help with the anxiety/ruminating. However, after reading some of the Seroquel message thread, including stuff about permanent side effects, I'm afraid to take it.
Posted by emmalie on October 12, 2002, at 16:33:04
In reply to Anyone switched to Lexapro? « ggrrl, posted by Dr. Bob on June 11, 2002, at 7:52:48
I am new to this site. I just switched to 10 mg of Lexapro from 20 mg of Celexa a few days ago. Does not seem like anyone has been posting lately about how they are doing on this drug. I'm curious how it's working for people . . .
Posted by Mr Christopher on October 12, 2002, at 17:04:18
In reply to Wish I could, posted by JaneB on June 11, 2002, at 13:12:29
Jane, it is out now.
Posted by Mr Christopher on October 12, 2002, at 17:09:01
In reply to so . . . how is everyone doing on lexapro?, posted by emmalie on October 12, 2002, at 16:33:04
Hey as far as switching is concerned, I caution anyone against switching unless they feel an adequate reason. For example, the current medication is not working any longer or the side effects continue and are unbearable. The bottom line is depression is a very ugly disease and if you are having success then why switch? Don't do it.
Posted by Mr Christopher on October 12, 2002, at 17:12:48
In reply to Day 6 on 10 mg and feeling terrible, posted by Micki on October 12, 2002, at 16:26:05
Don't give up, even though there is a ton of data to support an early on-set of action, most anti-depressants take from 4 to 6 weeks to get the full effect. Consider asking your doctor to bump you up to 20mg per day. This shouldn't increase side effects and possible assist in getting you out of bed and back to normal quicker. One more thing...The drug doesn't do it alone. Talk with friends, a therapist, whoever you feel comfortable with. You shouldn't rely on the drug alone especially now.
Posted by emmalie on October 12, 2002, at 17:17:15
In reply to Re: so . . . how is everyone doing on lexapro?, posted by Mr Christopher on October 12, 2002, at 17:09:01
I was on 20 mg of celexa for a month and it was working GREAT for me, except for the fact that i was experiencing severe jaw and head tension. So my pdoc switched me to lexapro, thinking that the side effect might go away. So far (3 days into it), i have less jaw tension, but i don't feel as happy and calm. guess i should just wait it out . . .
Posted by johnnylex on October 12, 2002, at 18:36:24
In reply to Anyone switched to Lexapro? « ggrrl, posted by Dr. Bob on June 11, 2002, at 7:52:48
For those of you wanting to know how some of us have been doing on Lexapro, here is my status at 4 weeks....
After 3 weeks at 10mg Lexapro my doctor bumped me up to 20mg this past week - today is my 5th day at 20mg. I have been pleased with Lexapro from a side-effects standpoint, but have found almost no relief for my anxiety and depression. Prior to this I was on 150mg of Effexor, which was doing an adequate job for my depression and providing some relief for my social anxieties. I needed to get off the Effexor due to unreasonable side-effects. I am hoping that the Lexapro will start to do its thing any day now, but it seems like I have given it enough time to get some amount of relief...so I am worried that Lexapro may not be the best medication for me. I'll post again with any changes.
By the way, thanks to everyone on this board for posting...it is comforting to know that I am not alone.
Posted by emmalie on October 12, 2002, at 19:23:46
In reply to Lexapro treatment status at 4 weeks...., posted by johnnylex on October 12, 2002, at 18:36:24
thanks for responding johnnylex.
That's kind of how I'm feeling after 3 days or so. Celexa definitely took away my anxiety but gave me bad jaw/head tension. Now, on lexapro, the jaw/head tension is much better but I feel more anxious. If only I could merge the two drugs into one . . .
Posted by Alan on October 12, 2002, at 22:01:56
In reply to Re: Amen! Alan ThankYOU, posted by GabbiX2 on October 12, 2002, at 15:15:36
> I'm printing that and bringing it to my Dr.
> He's refusing to re-prescribe Benzo's though they've worked for me before, and anxiety is ravaging my personal life (whats left of it)
> which of course compounds the anxiety.
>
> Thank-you
-----------------------------------------Here is the link to the posting by faschad that I mentioned in my last post.
http://www.dr-bob.org/babble/20020416/msgs/103521.html
Posted by GabbiX2 on October 12, 2002, at 22:18:31
In reply to Re: Amen! Alan ThankYOU » GabbiX2, posted by Alan on October 12, 2002, at 22:01:56
I can't thank-you enough ALAN
I can't switch Dr's (yes Accused of Dr. Shopping in Canada they can force you to go to only one dr. of their choice if they feel you've been doing that.
The fact that I've had to move 5 times in less than a year and can't afford to travel to the same Dr, Never had multiple prescriptions, and only once took more than my prescription amount of Ativan, or the fact that I voluntarily quit taking benzo's. doesn't seem to matter much.Sorry for the rant, just one more horror story..
Posted by Alan on October 13, 2002, at 1:32:14
In reply to Thanks for your trouble » Alan, posted by GabbiX2 on October 12, 2002, at 22:18:31
Posted by pharmrep on October 13, 2002, at 2:09:35
In reply to Day 6 on 10 mg and feeling terrible, posted by Micki on October 12, 2002, at 16:26:05
> This is my 6th day on 10 mg Lexapro and I feel just as anxious and depressed, and more lethargic than before. Could barely force myself to go to the grocery store today, and can't seem to bring myself to wash the dishes in my sink. Does this mean this is the wrong drug for me, or might this still turn around...I know 6 days isn't very long.
>
> Picked up the second prescription my doctor called in for me--Seroquel, which is an anti-psychotic, but she said to take it in a low dose (12.5 - 25 mg) and it may help with the anxiety/ruminating. However, after reading some of the Seroquel message thread, including stuff about permanent side effects, I'm afraid to take it.** it is too soon to decide on lexapro...if you can, give it a few more weeks...and if you can, try it without the other med...after 1 month, if you dont see what you want...then try 15mg, or add something else if you must.
Posted by Alan on October 13, 2002, at 10:29:19
In reply to Re: Day 6 on 10 mg » Micki, posted by pharmrep on October 13, 2002, at 2:09:35
YMMV but - A close relative told me about his experience with switching over to Lex. from Celexa for an anxiety disorder and it esentially went something like this:
....Been on Celexa since it came onto the market and it has helped me better than anything else I have ever taken (the list is to long to even think about). PDoc recently asked me to consider switching to Lexapro, which is similar to Celexa without the isomer that causes most of the side effects. However, the Lexapro made me extremely anxious so possibly the sleepiness side effect of Celexa was what I needed. I went back on the Celexa feel better but back to the usual sedation problem....
In response, I didn't want to say anything about the whimsical idea that all of the side effects would reside in the (removed) mirror image molecule and all the therapeutic effect would reside in the remaining molecule, but it's not surprising he discovered that on his own.
Doctors will fall for some pretty flimsy lines if delivered with a straight face and a pert attitude. Any biologist could tell them that when mirror-image isomers of molecules exist, it tends to be so that most of the biological activity resides in one isomer and the other is nearly inactive. However, the isolated-isomer version of Prozac never made it to market because it turned out to be dangerous, so the "one isomer active" rule may apply more to naturally occurring substances than it does to synthetic drugs.
Judging from the public statements I've heard, few authorities who are financially independent of Forest Pharmaceuticals expect Lexapro to be systematically better than Celexa for anything except the maker's bottom line. (There could be a few individual exceptions.) Same goes for Nexium compared to Prilosec and all these other analogous "next-generation" pills.
Interesting how the next generation always makes it to market just as the previous one's patent is expiring.
Skeptical in Seattle,
Alan
Posted by ANXIETY ANN on October 13, 2002, at 16:40:26
In reply to Re: Lexapro treatment status at 4 weeks...., posted by emmalie on October 12, 2002, at 19:23:46
> thanks for responding johnnylex.
>
> That's kind of how I'm feeling after 3 days or so. Celexa definitely took away my anxiety but gave me bad jaw/head tension. Now, on lexapro, the jaw/head tension is much better but I feel more anxious. If only I could merge the two drugs into one . . .*****
I have been taking Lexapro now for A Week. I too have terrible head /jaw tension in back of my neck, like a burning sensation. I only feel it when the lEXAPRO is wearing off. (after about 12 hours). I also have trouble sleeping and my anxiety is much worse. The reason i take it is for anxiety and panic. I,m not depressed at all. Is there anyone out there that Lexapro has helped expressly for anxiety. will the terrible neck and head pain go away? will I ever get a good nights rest? thanks for your help
Posted by Alan on October 13, 2002, at 17:17:59
In reply to Re: Lexapro treatment status at 4 weeks...., posted by ANXIETY ANN on October 13, 2002, at 16:40:26
> >
> > That's kind of how I'm feeling after 3 days or so. Celexa definitely took away my anxiety but gave me bad jaw/head tension. Now, on lexapro, the jaw/head tension is much better but I feel more anxious. If only I could merge the two drugs into one . . .
>
> *****
> I have been taking Lexapro now for A Week. I too have terrible head /jaw tension in back of my neck, like a burning sensation. I only feel it when the lEXAPRO is wearing off. (after about 12 hours). I also have trouble sleeping and my anxiety is much worse. The reason i take it is for anxiety and panic. I,m not depressed at all. Is there anyone out there that Lexapro has helped expressly for anxiety. will the terrible neck and head pain go away? will I ever get a good nights rest? thanks for your help
========================================
The reality is that for anxiety disorders, anxiolytics work at a much higher percentage of the time than do AD's (by the AD co's own stats)for the general population. There are exceptions and stastistics do not, as I suppose you know, apply to individual cases.Have you tried a benzodiazapine at all or alternatively other non AD treatments?
Please read my post directly above yours to explain why you are possibly feeling more rather than less anxiety. It is a bit technical but it speaks to your issue about anxiety related symptoms - in whatever form they appear...
Best,
Alan
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