Question:
I am a fifty year old male. I have had anxiety
attacks and GAD since I was seventeen. I was first
treated for it in 1996 with Paxil which helped but
side effects were terrible -- bad panic attacks all
night the first week, weight gain, brain zaps. Since then
I have tried Lexapro and Zoloft and Klonopin which
keeps the panic attacks away. Klonopin is all I'm
taking right now but the GAD is bad and I would have
to take a lot of Klonopin to overcome it...I now only
take .5 mg 2 x a day. I tried BuSpar for a few days
but felt weird. I'm going to have to try something
else can you suggest anything? I was put on
disability last year because I could not longer work.
I'd like to get well enough to go back to work and
lead a "normal" life....almost forgot what that is.
Dr. Heller's Answer:
When I'm presented with a problem like this, PTSD
(post traumatic stress disorder) is usually the
culprit. BuSpar (buspirone) often makes the PTSD
worse. Patients I see with similar complaints have a
number of "imbalances" within the serotonin system
making it difficult for any one medication to work
well, and most medications seem to make the problem
worse. There is no "mental health pill."
It's important for BuSpar (buspirone) to be taken
with a meal and to avoid grapefruit juice. BuSpar
(buspirone) works primarily for the "cognitive" GAD -
genetic worry. It is NOT a tranquilizer, but a
unique medication that seems to turn off the genetic
"worry" gene. These individuals are "cave guarders"
- always on alert for danger.
Sequencing of medications can sometimes be as
important as the actual medications themselves.
Remeron (mirtazapine) helps enormously with the PTSD,
including preventing the worsening of PTSD caused by
BuSpar (buspirone). When I see this combination I
frequently begin the Remeron (mirtazapine) at 30mg
nightly (lowering the dose if needed for next day
grogginess) and then start with a low dose of BuSpar
(buspirone) and go up slowly. An example would be
2.5mg nightly for two weeks, then 5mg nightly for two
weeks, then continue the 5mg nightly and add the
2.5mg in the daytime, etc. until 15mg twice daily is
reached. This works for over 95% of my patients with
this problem. 5% can't tolerate BuSpar (buspirone)
no matter what is tried, but the vast majority
succeed with this.
Once the individual is on an effective dose of
BuSpar, an SSRI can and should be added for the panic
disorder. If the borderline personality disorder
(BPD) and/or genetic depression are present, Prozac
(fluoxetine) is the best option. If not, I usually
prefer Lexapro due to its reduced sexual side effect
profile.
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