Hello doctor, I would like to ask you about treatment recommendations (maybe a few variations) for my condition. I have bipolar disorder type II, social and generalized disorder, and panic disorder. However, I am in constant depression for one year. I do not cycle anymore if I do, my hypomania is very mild and short-lived. Moreover, anxiety is debilitating. I am afraid to go out from home, feeling constant anxiety physical symptoms, such as sweaty palms and feet, chest pain, blood pressure rise, racing heart, and much more. I need something to ease my depression symptoms, but also something that would affect my anxiety in a positive way. My current medications are Lamictal 200 mg, 3x5 mg Tranxene, 5 mg Olanzapine, and 75 mg Venlafaxine. I am unable to take more Venlafaxine because from 150 mg my blood pressure and heart rate were out of control. My previous medications were Lithium, Depakote, Carbamazepine, Anxiolytics, Escitalopram, Zoloft, Quetiapine (which I cannot use because of its negative effects on anxiety and blood pressure, just for me), and Risperidone. I am wondering about Paroxetine, Citalopram and Prozac. If escitalopram 20mg was without any effects for two months, is it reasonable to try out Citalopram? I tried Prozac in past, I could not bear initial side effects but that were different times. Does it affect anxiety disorders from your experience? Paroxetine suits best. Which of these medicines could benefit me the most?
Hello. Thank you for your detailed query and history. With regards to your anxiety symptoms, you have tried out SSRI (selective serotonin reuptake inhibitor) and SNRI (serotonin-norepinephrine reuptake inhibitor) class of medications. So, I would like to suggest you try a TCA (tricyclic antidepressants) class of antidepressants like Amitriptyline 75-100 mg, Dosulepine 100 mg, or Nortriptyline 75-100 mg. They are indicated in people who have had partial results with SSRI or SNRI medications. If you do not wish to try out the TCA and coming back to your query about the three medicines, the best results for anxiety will be with Paroxetine between 12.5 mg to 37.5 mg, and Citalopram will also work fine at 20 mg. In addition to these, you can also consider augmenting the action of these by adding Mirtazapine 7.5 mg at night. I would like to suggest that you should consider reducing Olanzapine to 2.5 mg, since you are not in hypomania, and have depressive symptoms. Reduction to 2.5 mg will make it an augmenting agent again for the antidepressant, and also further help with your anxiety issues. Also just to mention, some people do get benefit from having a few sessions of CBT (cognitive behavioral therapy) from a Clinical Psychologist.