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Today I went to my PsyDoc to discuss abt your

recommendations. She prescribed me a...
Today I went to my PsyDoc to discuss abt your recommendations. She prescribed me a new set of meds :
1) Aripiprazole 15mg (x-----x-----1)
2) Escitalopram 20mg (x-----x-----1)
3) Intalith CR 450mg (1----x----1)
4) Clonazepam 1mg (1------x-------1)
5) Nortriptylene 25mg (1----x-----1)
Sir, is this a superior combination compared to my previous medication for my schizophrenic depression with severe GAD.
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Answered in 2 minutes by:
9/12/2013
Dr. Kaushik
Dr. Kaushik, Psychiatrist
Category: Mental Health
Satisfied Customers: 4,688
Experience: MD Psychiatry
Verified
Dr. Kaushik :

Greetings !

Dr. Kaushik :

Welcome to the site.

Customer:

hello sir

Dr. Kaushik :

Well everything else seems to be appropriate in your drug regime except for the fact that she has added nortriptyline 25 mg twice a day

Customer:

what should have been done sir

Customer:

kindly help me, i m in crisis

Dr. Kaushik :

which i am not comfortable with since first of all nortriptyline being a TCA class anti depressant comes with a slew of side effects ranging from sexual dysfunction to ECG changes etc and on top of this it is not supposed to be given when escitalopram is being used because their use together can lead to a life threatening situation called as Serotonin syndrome.

Customer:

i c

Dr. Kaushik :

You may mention to her this that the combination of escitalopram and nortriptyline may precipitate a life threatening serious complication due to excessof serotonin levels in the body caused by this combination which will land you in emergency.

Customer:

ohhhhhhhhhhhh

Dr. Kaushik :

so i personally do not approve of use of nortriptyline with escitalopram , any one of these shall be used , preferably escitalopram both because it is

Customer:

i must discuss this with her

Dr. Kaushik :

better in effiacy

Dr. Kaushik :

plus it has least side effects .

Customer:

sir

Dr. Kaushik :

as compared to nortriptyline.

Customer:

do u remember my earlier drug regimen

Dr. Kaushik :

i am afraid i do not remember , can you please revise it now.

Customer:

sure

Dr. Kaushik :

http://www.mayoclinic.com/health/serotonin-syndrome/DS00860/DSECTION=causes

Dr. Kaushik :

before that

Dr. Kaushik :

please follow this link ,

Dr. Kaushik :

as this will tell you where this regime is going wrong by using both escitalopram and nortriptyline together.

Dr. Kaushik :

You may in fact show that to your psychiatrist as well if the need arises.

Customer:

sure

Customer:

i will do that

Customer:

as i m in a crisis\

Customer:

Sir, u had suggested the following meds

Dr. Kaushik :

please go ahead.

Customer:

1) Duloxetine 60mg ( x------x------1 )

2) Aripiprazole 10mg ( 1------x------1 )

3) Lamotrigine 200mg ( x------x------1 )

4) Clonazepam 1.5 mg ( 1---x----1 )

5) Pregabalin 150mg ( x-----x-----1 )

Customer:

Sir, i have a few things to narrate

Customer:

I like Duloxetine better than escitalopram

Customer:

i mean , i feel more comfortable

Customer:

sir, now, coming to the mood stabilizer phase

Customer:

whi will be better for me ?

Customer:

Lithium or Lamotrigine

Customer:

r u there sir ?

Dr. Kaushik :

yes.

Customer:

i have tremendous depression

Customer:

n anxiety

Dr. Kaushik :

i am assessing ..

Customer:

ok

Dr. Kaushik :

so this may take a minute.

Customer:

sure sir

Dr. Kaushik :

yes..

Dr. Kaushik :

now hear me out ..

Customer:

sure sir

Dr. Kaushik :

you can keep cymbalta as it is and choose not to use escitalopram

Customer:

ok

Dr. Kaushik :

aripiprazole has been approved by the doctor herself , but her dose is 15 mg as opposed to mine of 20 mg in two divided doses of 10 mg each.

Customer:

yes

Dr. Kaushik :

so you may start taking 20 mg at night and after 1 month you may consider coming down to 15 mg once symptoms are better .

Customer:

ok

Dr. Kaushik :

clonazepam also has been retained by her so you may continue take 1 .5 mg twice a day and after 1 month reduce it's dose to 1 mg twice a day as she has suggested.

Customer:

ok

Dr. Kaushik :

As far as mood stabilizer is concerned , lithium is better in efficacy but it has a lot of side effects

Dr. Kaushik :

ranging from hypothyroidism ,

Dr. Kaushik :

liver impairment,

Dr. Kaushik :

kidney impairment,

Dr. Kaushik :

ECG changes

Dr. Kaushik :

skin rashes.

Customer:

ok

Dr. Kaushik :

neurological symptoms like tremors , loss of balance and poor coordinatin , etc

Customer:

ic

Dr. Kaushik :

on top of this there looms a constant fear while using it about lithium toxicity

Customer:

ic

Dr. Kaushik :

and therefore every 3--6 months serumk levels of lithium are to be checked for toxicity

Customer:

my God

Dr. Kaushik :

so basically due to so many side effects this drug although being effective has gone out of favor

Dr. Kaushik :

instead ask doctor to replace lamotrigine with either sodium valproate or divalproex sodium.

Customer:

but lamotrigine has not been tried yet sir....

Dr. Kaushik :

sodium valproate can be used enchorate chrono or valprol or valtec cr 300 - 500 mg twice a day.

Customer:

you had recommended it and today i discussed it with my doc\

Dr. Kaushik :

and if you choose divalproex then it is available as divaa od 250 mg -750 mg / day

Dr. Kaushik :

dayo OD is another brand of the same drug

Customer:

which one will be superior for me sir.....divalproate or lamotrigine for my recurrent depression

Customer:

low mood

Dr. Kaushik :

so sodium valproate or divalproex will be supperior any day as compared to lamotrigine

Customer:

loss of interest

Dr. Kaushik :

yes for that also.

Dr. Kaushik :

it will act as an augmenting agent to counter your depressive features .

Customer:

so, lamotrigine is inferior to valproate

Customer:

for my low mood etc

Customer:

i dont have mania

Customer:

i have recurrent depressive features

Customer:

without mania

Dr. Kaushik :

yes.

Customer:

low mood...lack of interest in studies...

Dr. Kaushik :

i have considered that too before answering.

Dr. Kaushik :

yes.

Customer:

i c

Customer:

plz suggest be how to take Divalproex

Dr. Kaushik :

it is readily used for depression along with a chief anti depressant like escitalopram or cymbalta.

Customer:

i mean the dsosage

Customer:

i c

Dr. Kaushik :

It will be better if you taking long acting version of divaloproex such as Divaa OD or Dayo OD which is to be taken only once a day starting at dose of 250 mg for 1st week , then 500 mg for 2nd week

Dr. Kaushik :

and 3rd week and then 750 mg from 4th week onwards and maintain on this .

Customer:

what should be the final dosage of Divaa OD

Customer:

oh, ok

Dr. Kaushik :

750 mg.

Dr. Kaushik :

/ day as a single morning dose.

Customer:

i weigh 104 KG sir

Dr. Kaushik :

yes no problem

Customer:

morning dose ?

Dr. Kaushik :

this will be suitable for your weight.

Dr. Kaushik :

yes morning dose after or with breakfast.

Customer:

but it causes sedation, isn't it , sir

Dr. Kaushik :

Not really.

Customer:

and i have studies hanging over my head

Customer:

oh, ok, i m sorry sir

Dr. Kaushik :

do not worry.

Dr. Kaushik :

i have not encountered many people who have taken this drug and had complained of sedation.

Customer:

now what abt Pregabalin.....whether to take it or not sir.....i have severe GAD.......

Dr. Kaushik :

You may come off it .

Customer:

it really helped my anxiety

Dr. Kaushik :

i think the revised drug regime will bypass the need for it's use.

Dr. Kaushik :

i know ..

Customer:

ok

Dr. Kaushik :

so what you can do is to taper it slowly.

Customer:

ok sir

Customer:

Thanks a lottttttt :)

Dr. Kaushik :

while allowing the newer drug regime settle and take over and control your anxiety and depression and schizophrenic symptoms.

Dr. Kaushik :

I hope this helps.

Customer:

one t6hing sir

Customer:

last thing sir

Dr. Kaushik :

what ?

Customer:

regards ***** ***** memory

Customer:

working memory impairment

Customer:

visual learning and memory

Dr. Kaushik :

in schizophrenia new learning skills and memory generally impaired.

Customer:

oic

Customer:

so, there is no cure

Customer:

so, sir, should i stay away from my academic persuits

Dr. Kaushik :

improvement can be seen once your associated depression lifts plus the mentioned drugs will help in improving learning and memory ability.

Dr. Kaushik :

well

Dr. Kaushik :

academic pursuits may lead to unnecessary stress and pressure as they come with lot of demanding schedule and this may precipitate a long dormant schizophrenia and convert into full blown.

Customer:

i c

Dr. Kaushik :

plus the cognition/ thinking rarely can reach previously high levels.

Customer:

i c

Dr. Kaushik :

so if you ask me , i will say that you should train yourself for survival in a job or profession where less amount of higher mental functioning is required.

Customer:

i c

Customer:

I get yr point sir

Customer:

Thanks a lot for your time and valuable input sir

Dr. Kaushik :

i am sorry if you got discouraged a bit , i am just placing facts.

Customer:

i understand sir

Dr. Kaushik :

at the end of the day you will be able to perform in whichever field if you are healthy both physically and mentally , therefore have some realistic and achievable goals in life.

Dr. Kaushik :

i hope this makes sense to you.

Dr. Kaushik :

wish you all the best.

Customer:

thanks sir

Customer:

thanks a TON

Dr. Kaushik :

you're welcome.

Dr. Kaushik :

Take care.

Dr. Kaushik :

Warm regards.

Customer:

yup

Customer:

Warm Regards

Dr. Kaushik
Dr. Kaushik, Psychiatrist
Category: Mental Health
Satisfied Customers: 4,688
Experience: MD Psychiatry
Verified
Dr. Kaushik and 87 other Mental Health Specialists are ready to help you
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Customer reply replied 4 years ago

Dear Sir,

I went to see my PsyDoc and gave her your opinion today...but she is becoming a little bit rigid in her prescription. She bluntly told me that nothing will happen. Thats why I m thinking of seeing a new PsyDoc. Presently, I am thinking of taking your recommendations to a new PsyDoc.

Sir, I have just one little bit of confusion. For my very low mood....is Divalproex better than Lamotrigine....i have been on both earlier. Kindly guide me Sir. (I have just one sided severe depression and no mania at all).

kind regards


If there is no bipolar depression then lamotrigine perhaps will do more good than divalproex for unipolar depression, so you shall use lamotrigine.

You may seek help from a new psychiatrist who is open minded and flexible but you may find it difficult to convince a psychiatrist to follow your recommendations completely so even if a psychiatrist is willing to follow some of the recommendations then you shall accept that and go ahead with him/ her.

Regards.

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Dr. Kaushik
Dr. Kaushik
Dr. Kaushik, Psychiatrist
Category: Mental Health
Satisfied Customers: 4,688
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Experience: MD Psychiatry

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