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Dr. Kaushik
Dr. Kaushik, Psychiatrist
Category: Mental Health
Satisfied Customers: 4672
Experience:  MD Psychiatry
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I am 77 years old and have been suffering from panic

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I am 77 years old and have been suffering from panic disorder and depression for many years. I was taking 150 mg Effexor XR and 2mg Xanax XR divided during the morning and evening for over 12 years with wonderful success. Suddenly three years ago after numerous injections of steroids for spine problems, the meds suddenly stopped working, at least the Xanax but my psych doctor wasn't sure about the effexor.
From one moment to the next, after all that time, I got a really bad panic attack and from that one moment on, both panic and anxiety attacks constantly. We tried upping the Xanax but nothing worked. He got me off the Xanax by using Ativan but I went through hell because I metabolize meds very quickly.
After getting off both Xanax and Effexor you will be surprised that I went back on them again because it seemed nothing else was working and I was almost in a state of total collapse.
Now here it is exactly a year later and while I am so much better that I was a year ago, I suddenly am having a problem again. Let me add that I am now on 3mg XanaxXR daily, divided by 1mg morning, afternoon, and bedtime. Effexor dose stayed the same.
During these past three, four months, I felt the effexor wasn't working as well and we tried several antidepressants, the last being Viliibryd, starting at 1/2 of the lowest dose but it seemed to give me diahrrea. On at least two weeks and off a couple. Of course suffered side effects and withdrawal symptoms. Then on to Serzone (whatever the generic name is now) with same results. Now back on Effexor and Xanax by themselves. I said no more of the up and down because I can't take the effects anymore.
I've been on this regime for 5 days today. Starting a couple of days ago I started noticing getting palpitations starting about an hour or so after taking my Effexor. By around one or so, they have gotten pretty severe. I am able to call my psych doctor on weekends and I called him today because I could not figure out what or why the change that was happening. Before all this I was feeling good but extremely tired in the a.m. after I took my morning dose of Xanax. So tired and sleepy I have to go back to bed to sleep it off. My doc wouldn't change the Xanax dose because we had gone up and down on the antidepressants too close and too often and he wanted me to stay on one thing for awhile to see what happens.
Today when I told him of my problem he said he wanted me to keep a chart for one week, putting down the exact time I took my meds and then call him next week. I am to take them right on the dot, no messing around with the time. He said with all the changes, if I haven't been as observent when I take my meds it could cause a problem especially with my fast metabolism. I have to be honest and say I haven't taken them right when my alarm goes off my I phone like I did when I first started taking them.
I said all that to ask you could this be the reason for the problem I'm having with the palpitations? I started taking my 1mg Xanax at 7 a.m. and then changed it to 7:30 or 8 a.m. as I started feeling better. I take my second dose at 2 p.m. and last dose at 9:30 p.m. I'm pretty good at taking them when my alarm goes off but honestly? The better I felt the later I got around to taking them.
My question is: why is it so important to take these meds exactly at the same time every day? I know during the 12 years I was in recovery using only 1mg. Xanax daily and the Effexor, I took them whenever I remembered to take them and never had a problem. However, the truth is I don't remember how long it took me to get to that point but I do not remember having any problem with taking the meds like I do now. I know I did not have a problem with fast metabolizm then.

Hi there,

Welcome to Just answer !

I am sorry to learn about your relentless struggle to find a formidable combination for your anxiety / panic attacks and I empathize with you.

Well I will agree with your doctor's advice to take the medications on the mentioned time, the reason being when you take them not as per the prescribed schedule the levels of these drugs in your plasma / blood undergo fluctuation leading to unstable levels which can itself result in precipitation of a panic state. Besides you being a fast metabolizer need to take more care in taking the medications as per the schedule because the half life of these drugs in your case is reduced as compared to others which may lead to a more likely fluctuation in drug levels when the next dosing is not on time.

So prepare a chart and co-ordinate it with a timer and follow it up regularly , I known this can be stressful but this is the only way to stick to one drug regime and reap benefits from it , more so when you have a limitation in the form of a fasts metabolizing system.

Also I may add here that just in case your present drug regime does not prove to be as effective as you desire then you may ask your psychiatrist to try out what is called as 'California Rocket Fuel' which is a term given to the formidable combination of Effexor and Remeron and this combination is likened to be the remedy for treatment resistant depression and treatment resistant anxiety disorders including panic attacks. So since you are already taking Effexor , you just will have to add remeron( mirtazapine) at dose of 15-45 mg at bedtime , starting at lower dose first and then titrating up the dose as per the need.

So kindly discuss this with your doctor.

Kindly see link below for more in formation on California Rocket Fuel..

I hope this helps.

Wish you all the best.

Please kindly leave a Positive rating if you are satisfied with the answer as only then will I be credited for my service.

If there is any further assistance needed please feel free to ask using the reply button.


Customer: replied 4 years ago.

Thank you Dr. Kaushik for your answer. However, I have a question about California Rocket Fuel. I wasn't able to get into the site but my question has to do with the avisability of taking the Remeron at night along with my 1mg Xanax. Won't this make me feel too sedated the next morning? I already am dealing with this problem and it's driving me crazy,

I was up so tired and with no energy or any feelings of joy or hope. I have to go back to bed for a couple of more hours. I don't know if this has to do with my going up and down on different drugs that I mentioned to you in my earlier question and will eventually go away but I am having a hard time dealing with this low-down feeling. It's only after late afternoon or early evening that I begin to feel like myself but by then it's time for bed...10 p.m.

Will adding remeron to the xanax xr and effexor xr help this situation in any way?



Thanks for the inputs.

Well the above link for the site is working just fine , you shall click on it again and try reading the information about 'California Rocket Fuel'.

Now as far as your concern about taking remeron at night with Xanax I there, I believe you can cut down on the dose of Xanax to 1/2 of 1 mg after 1 week of taking full 1 mg Xanax with 15 mg remeron. Initially there may be a little next morning drowsiness but it will go away after 1 week once your body starts adjusting to remeron addition. Also I may address here that your feeling of tiredness / no energy / no pleasure and hopelessness , all of these are attributable to your underlying depression which has spiraled out of control most possibly owing to your frequent tampering with the drug regimes.

So all you need is stability on one formidable drug regime and that can brought about with the use of California Rocket Fuel , but you got to give the drug regime a realistic chance in the form of at least 2-3 weeks so as to show you the efficacy against depression and anxiety disorders for which it is world renowned.

And as far as initial sloppiness and drowsiness is concerned that will take care of it's own once remeron gets adjusted in your system within a few days time , and once that happens you shall just cut down on Xanax and may in fact later stop it completely when your symptoms have started to wane off with the use of this formidable drug regime.

So I will encourage you to try out this drug regime , giving it some time to prove it's worth and may be this time you will find something to hang on with for good.

I hope this helps.

Wish you all the best.

Please kindly leave a Positive rating if you are satisfied with the answer as only then will I be credited for my service.


Dr. Kaushik and other Mental Health Specialists are ready to help you
Customer: replied 4 years ago.

Thanks again, Dr. I was finally able to click on the site you mentioned. It all sounded great until I got to the last paragraph or so. The problem? I am overweight and cannot take meds to lower my cholesteral (sp?) because it gives me awful pains in my legs, etc. We've tried them all. I am now just starting a weight loss program but until I lose weight, according to the site, I can't take remeron.

I wish I could but it's not advisable right now.

Thanks for your help in recommending the California Rocket Fuel. I know my p.doc is aware of it because 13 years ago it was part of the med cocktail he gave me in the very beginning of my care and it worked wonderfully.

Thanks again for your help. I am now 4 days into my taking my meds on time regime. Still don't feel so great but if I'm not wrong, both you and he said it would take at least a couple of weeks to see and feel the difference.


Well I can understand your concerns about weight gain and cholesterol levels so although you do not use this drug regime right now but you shall keep it as a back up in case the present strategy of timely dosing does not work and also when your weight gets controlled.

Yes it will take roughly 2 weeks for you to start responding to the change in your drug intake strategy, so you shall wait patiently and continue to stick to the revised treatment plan.

I hope this helps.

Take care and God bless.


Customer: replied 4 years ago.

Thanks again, Doctor K. ~ You said in your last reply "Yes it will take roughly 2 weeks for you to start responding to the change in your drug intake strategy, so you shall wait patiently and continue to stick to the revised treatment plan."

May I ask you what sort of response should I be expecting? Right now I still have one good day to half a day and the next day I feel badly. Are you saying the ups and downs will decrease and I should start feeling pretty well as each day goes on?

It's been so very long, at least two years since I felt good even a week at a time.

Anyway I know you have the answer and I'm hoping it will be a good one.

God bless you, too. He is the One that has gotten me through all this even though there were times I doubted and felt so alone and hopeless. I want you to know that you have given me more information that is helping me stay the course than my own doctor. He is a wonderful man but just can't explain things the way you do. Maybe you are an answer to my prayers?

To anyone not going through what I have it's hard for them to understand not only how I'm feeling but also how long two weeks can seem as I wait to see if what I'm doing is going to work or not. I don't blame them, but two years of this is a very long time to wait to get back to feeling "normal". And, of course, it's the not knowing what the end results will be that can drive one crazy. If the regime I'm on ends up not working and I start on the added remeron, the merry-go-round starts all over again as I sit and wait.

Really feeling sorry for myself, aren't I?

Awaiting your answer....



I can see that you are eagerly waiting for the revised drug regime to kick in and I will encourage you to hold on to this belief as positive mind set helps in achieving what we strive for.

Now as far as what to expect after 2 weeks , on this I will say that your mood swings between lows and highs will become less severe and less frequent with more highs spanning throughout the day than lows and as some more days pass by you will see more days in a week to be good days for your mood and this will be carried forward to finally rendering you symptom free.

I feel that we have options for you if God forbid this strategy does not work ( which I do not think will be the case though ) , so do not loose hope and continue to have patience and start taking each day as it comes. You will get past this phase , so hang in there.

God bless and take care.

Wish you best of health and speedy recovery.

Warm regards..

Customer: replied 4 years ago.

Hi Dr. K....

Sorry I couldn't get through to you yesterday. Something must have been wrong with the system.

I want to thank you for answering all my questions. You have helped me so much by the information you have given me plus giving me straight answers. I feel so much more relaxed now that I know what to expect. The not knowing or being given approximate timelines drives me crazy. I keep telling my p.doc this but he doesn't seem to get it as far as my personality goes.

I will be in touch as time goes by. Thanks again and God bless you.


You're welcome.

Take care.


Customer: replied 4 years ago.

Dr. Kaushik, there is no place to go to credit your service.


Do not worry . next time whenever you need my assistance then you shall pay me. As of now I considered all your queries as follow up. So relax and take care.


Customer: replied 4 years ago.
Hello Dr Dr. Kaushik, I just tried to get to you but not sure I did. I am having another problem that I need your help with. For the past two weeks or so I have been taking my Effexor XR. 150mg and Xanax XR. 3mg. daily right on time daily, If you remember I wasn't doing that plus was trying out new antidepressants at the same time, My psych doctor told me to stop all other meds and just stay on the two meds but take them exactly at the time diagnosed. I have been doing that but suddenly over the past two days I have been having a problem waking up in the morning. I have to literally drag myself out of bed to take my morning meds, then during the day I very tired, so tired I feel asleep twice yesterday while reading. This morning was even worse. Aside from the tiredness and sleepyness, I can't seem to focus my eyes right. I am just too sedated-feeling to accomplish anything and need to go back to bed,
In the beginning, two weeks ago my doctor said when my receptors straightened out (or whatever they do) he would consider start lowering my Xanax dose. For 12 years I only needed 1mg. divided .5 twice daily. I don't know if I can go that low again but could it be that 3mg. is too high for me now? And could it just take 2 weeks or so taking the meds on a regular timeline get my receptors working properly?
Please give me your thoughts and advise. I have begun to trust your knowledge and answers a lot.
Until I hear from you,
What time of day are you taking xanax xr ?
Yes 2 weeks is a good enough time for receptors to start responding to the drugs and so one can expect improvement to occur this early.
I will get back to you once you reply to my queries.
Customer: replied 4 years ago.
I take 1mg Xanax 8 am - 2 pm- and 9:30 pm
Here is the problem , xanax has started to produce sedation possibly after reaching it's maximum potential at it' s receptors after 2 weeks of use at this dose and therefore the morning dose has started to produce excessive sedation thus warranting revision in the dose. And anyways this was expected to happen sooner or later due to increase in the dosage of xanax from a much lower dose that your body has been accustomed to for years together to a much higher dose that you are currently taking, if there had been a gradual increment in dosage in your dose of xanax then you would have tolerated this current dose better without having to endure sedative side effects.
Anyways as of now you got to cut down the morning and afternoon doses to 0.5 mg dose while continuing on 1 mg dose in the night.
This will take care of your current sleepiness and sloppiness.
I hope this helps.
Wish you all the best.
Customer: replied 4 years ago.
Thank you for your reply, Dr.K. The problem that concerns me is because I metabolize Xanax so quickly, if I go down 1 whole mg a day, I will begin to suffer from withdrawal symptoms. They can be pretty severe, believe me. If I am right about this, is there another, slower way to cut back? I know it will take longer but will be easier to deal with. If I am wrong about withdrawaling, please let me know.
Thank you...
No you are not wrong about the possibility of development of withdrawal symptoms, more so when your metabolic rate is fast, which further raises the chances of withdrawal development.
So taking this into account I suggest that you try this below mentioned strategy.
First try to reduce the morning dose to 0.75mg while continuing rest of the 2 doses of 1 mg each in the afternoon and night intact and continue this for 1 week.
Then you shall further reduce the morning dose to 0.5 mg while continuing with the rest of 1 mg doses in the afternoon and night as they are, without any changes and continue this for 1 the end of this week you shall assess your present symptoms of excessive drowsiness , if they have been resurrected then you shall continue on this revised drug regime for good , with no more dose reduction being required.
But if the symptoms still persist then you shall have to come down to 0.5 mg dose in the afternoon over the course of 2 weeks in the same way as you reduced the morning dose, thereby making you to slowly and safely come down to the safe yet effective doses of 0.5 mg, 0.5 mg and 1 mg respectively in the morning , afternoon and evening which will not only allay your current symptoms but also will be effective against your primary cause.
I hope this helps.
Wish you all the best.
Customer: replied 4 years ago.
Thanks Dr. K. for your reply. However, this brought up another question that I need to ask to be sure we're on the same page.
Before my receptors filled up (?)I would take my 8 am 1mg xanax and would feel awake and a little shaky until I took my 2 pm dose. Then things would settle down and by late afternoon I would feel "normal". But as time has gone by and I started taking my meds at the same time every day, little by little the am shakyness went away until it got to the point where I wrote to you the other day...I started having to set the alarm for the am dose and drag myself out of bed to take it and then go back to bed to sleep, then wake myself up again at 9 am to take my 150mg effexor. The back to sleep or try to get up. Obviously the xanax was too much.
You suggested I cut the morning xanax dose to 75mg for a week, etc. However, just to be sure I explained the right situation I'm going through to you, I'm asking you still believe going down to 75mg in the a.m. is the right way to go or should I instead cut back on the night time dose? I really sleep good at night and hate to lose that and I'd rather cut the morning dose, but would that help me in due time to get back my day-time energy?
Thanks again,
You see it is the morning dose which is the culprit and responsible for excessive daytime sleepiness so it should be brought down to 0.75 mg dose and if the need arises then further reduction can be done to 0.5 mg dose , while the night time and afternoon time doses shall be maintained as they are being used right .
I reckon you shall give this strategy a try and see for yourself how you respond to this change within a week or two which then shall allay any sort of doubt about this strategy.
I hope this helps.
Wish all the best.
Please kindly leave a Positive rating if you are satisfied with the answer as only then I will be credited for my service.
Customer: replied 4 years ago.
I understand completely now but I have one tiny sort of non-medical question to ask you. Are you saying the dropping one .5mg Xanax XR and substituting it with a regular .25 mg. can make that much difference in how I feel? That little dose can make that much difference?
God Bless,
I did not say that, may be you misunderstood , here I will explain it again.You start with 0.75 mg of xanax xr morning dose, 1 mg of xanax xr in afternoon and night each.After 5 days if current symptoms of excessive sleep and drowsiness do not improve then further come down to this drug regime 0.5 mg xanax xr in the morning and 1 mg xanax xr each in the afternoon and night and maintain on it for 1 week and this shall take care of your symptoms for sure.I hope this helps.Wish you all the best.Regards.
Customer: replied 4 years ago.
Sorry, Dr. either I didn't explain myself correctly or I have it all wrong. I take two 0.5 Xanax XR three times daily = 3mg total, right? You said to cut the morning dose to 0.75. Doesn't that mean I need to take one 0.5 mg and one 0.25mg to equal 0.75mg? Or am I all wrong about the a.m. doses. I didn't know Xanax XR came in 0.75mg.

No you got it right. This is what you are supposed to do. I am sorry I did not know you were taking 2 Xanax xr doses of 0.5 mg each.

Please follow what you have understood above, that is to take one 0.5 mg and one 0.25 mg = 0.75 mg in the morning , two 0.5 mg doses each in the afternoon and night.


Customer: replied 4 years ago.
Dr. Kaushik, I just lowered my xanax dose by .25 this morning for the first time. I know it probably will take a few days before my receptors react to the lower dose. Right now, today, I feel as tired and sedated as I have felt for the past 4 days and I really don't like it. I hate feeling this way, Therefore, I have to ask how much difference will the discontinuence of this tiny dose have on my body and mind. Can such a small cut of just .25 make that much difference, enough to take away this feeling of sedation and brain freeze?
Well I can understand your concern and frustration regarding the pervasive symptoms but to be frank within and day of lowering of dose one cannot expect miraculous recovery after all it is human body that we are talking about which takes some time to readjust itself to the change in dosage and that is why I have asked you to wait for 5 days after reducing 0.25 mg dose before another 0.25 mg can be reduced.
So I humbly request you to patiently follow the right withdrawal protocol because if we try cutting corners and advice faster withdrawal then it may backfire as a strategy which I must admit it quite commonly does and result in untoward withdrawal side effects which will only worsen the picture and unnecessary delay your recovery.
So reduction of 0.25 mg dose may look insignificant to you but it is a small yet utmost important step in relief of your symptoms.
I hope this helps.
Wish you all the best.