PTSD/Anxiety/Depression - Huge Stack and Doses - Looking for Thought

[DepPTSDAnxiety]

Hey All,

So unfortunately the past two years I've been battling with some severe PTSD that's also lead to severe anxiety and depression. It's really bad and at the just holding on point. Fantastic career, family, life and friends - have all been slaughtered by this battle.

I've been seeing a psychatrist, who I had been seeing profolactically because of the nature of my previous work (since then have left). There was a gap between when I was seeing the Dr. profolactically and when I started getting extreme PTSD, Depression and Anxiety symptoms - but thanks to a small support system - got back on track.

Anyway, currently I'm prescribed a range of medications daily, and while I'm doing my research, trusting my doctor etc - I do want to know other folks who are fighting the battle think about my current stack. I suppose it's working, because I'm not nearly as bad as I was two years ago - but I'm not myself - not even close. I'm also suffering daily still from symptoms of all three diagnosis (to the point where it's left me apparently unable to function regularly in the 'real world').

My Current Medications

1. 375mg Venlafaxine HCl ER / Effexor ER
2. 1.5 mg clonazepam / Clonopin in the am, 1mg clonazepam in the pm (down from 3mg split, 2.5mg daily)
3. 1mg Risperdone / Risperdal (recently up from .5mg)
4. 40mg propanolol 3x a day
5. 150mg trazodone nightly
6. 40mg Vyvanse / lisadexamphetamine daily, alternative was like 40mg-60mg of Adderall XR a day (which I may switch back to due to cost of the non-generic vyvanse)
7. 1mg Alprazolam as a PRN for when things get really really bad (hitting myself, just complete spirals, walking around the city just because I have to get on the move etc.)

My concerns:

1. While I started on Trintellix the cost and lack of response moved us to Effexor especially because of it's SNRI effects. The Effexor dose was titrated up responsibly - but it's just such a high dose (375mg) and I believe above what's typically recommended in an outpatient setting. Coming off this one day is not something I try not to think about given what I've heard about withdrawal symptoms.
2. I'm worried about physical dependence on the benzodiazapines, which since I was on 3mg for at least 6 months, and no end in sight for the 2.5mg - has surely taken hold. Not as concerned about mental dependence because I couldn't really tell you if I had taken the medication or not in terms of noticiable difference.
3. Risperidone - I was hesitant to go on this because it's A) an antipsychotic which has a whole range of social stigma attached to it (to the point it actually limits my employability), and because of the long-term affects of the medication. I'm on a low dose I believe (1mg daily), but I don't even know if that's a dosage high enough to be 'effective'. Though definitely scared to go up and start getting things like extrapyramidal side-effects.
4. Combining downers and uppers every day. I understand that they work on different systems with some cross over especially in specific dopamine receptors - but lawd.

Anyone seen something like this stack? Red flags other than what I've picked up?

The sad part is, before all this - I had no overt mental health issues and a really good life. Now I'm just a shell of what I used to be, and I don't even think it's overmedication at this point.

Clinically I know it doesn't matter, but my first run-in with a hospital before all this started for an unrelated issue seems to have shown that I have some wicked tolerance for drugs - even very strong opiates - and I had never taken a drug in my life at that point (I couldn't even take Tylenol with Codeine after dental work because it wrecks my stomach just making pain worse). But while in the hosptial I was getting shot up with morphine and fentanyl to near zero effect.

Any thoughts, suggestions, alternatives, or similarities to doses you've been on or seen / experienced?

While I trust my psychiatrist, and objectively he's taking the appropriate steps in terms of best-practice it seems - I have been thinking about maybe reaching out to another psychiatrist - just to get a second opinion / med check. Anyone ever do that before?

 

[joeylittle]

Putting aside your concerns about the number of meds you are using, for a moment - Do you believe that they are helping? As in, did you notice an improvement in a specific symptom(s) when you started them?

And I'm curious, what order you were prescribed them in, and how much time (if any) there was between add-ons...

 

[Sideways]

Definitely seen stuff like this before with comorbid mental health issues.

Are you receiving other forms of treatment besides medication? That will help. A lot.

I'm worried about physical dependence on the benzodiazapines, which since I was on 3mg for at least 6 months, and no end in sight for the 2.5mg

I'd be worried about this too. Especially the loss of effectiveness of the drug over that period of time, together with physiological dependency.

that I have some wicked tolerance for drugs - even very strong opiates - and I had never taken a drug in my life at that point

This is usually about the way an individual's body's metabolism. Which is what it is:)

Anyone ever do that before?

Yup. A second opinion is a great idea. And each time I've done it? I've spoken to my pdoc about it beforehand.

 

[DepPTSDAnxiety]

Putting aside your concerns about the number of meds you are using, for a moment - Do you believe that they are helping? As in, did you notice an improvement in a specific symptom(s) when you started them?

And I'm curious, what order you were prescribed them in, and how much time (if any) there was between add-ons...

I believe that at least the combination is helping, but I can't be sure which is most effective in determining what symptoms.

Started on just the venlafaxine and 50mg trazodone which kept being titrated up over time due to lack of progress in response. Started at 37.5mg and it was at least two weeks between jumps of 37.5mg mostly. Then the propanolol was added as a PRN, but switched to 3x a day. I believe at that point it was helping with the constant heart pounding from the second I woke up to bed, and there was hopes it could help at least control the constant drenching sweat. Then the clonazepam was added, first .5 or 1mg, then titrated up as it didn't seem to be doing anything for me.

The risperdal was something I dreaded having to take (getting into the antisychotics actual disqualifies me from jobs in my profession), but the agitation and never being settled and constant fight or flight. I was also experiencing significant prostate pain at that point, where having an orgasm (male) would burn and be physically painful. The risperdal cleared that pain up overnight or a few days like a miracle.

I can say, especially when talking with my wife that I'm hundreds of times better off than where I was when I started the medications.

I'll discuss with my doctor about going to check with another psychiatrist for an opinion - to see if they can offer any other options or ideas.

And unfortunately no, I'm not in counseling. I was for a brief period of time, but it became way to expensive even with insurance. I've been on that waiting lists for several schools and other services in the area for near a year now (unfortunately I think COVID has really messed that up).

 

[DepPTSDAnxiety]

It's been tough because during the entire time I've been not only dealing with the PTSD, depression and anxiety, but a seemingly endless amount of additional life stressors / events that I feel like I have no reserves left and absolutely zero resiliency.

I used to make great money, was at the top of my field, had a career that was on the fast track, and was so happy and positive - and now I'm lucky that I can drive to the psychiatrist half the time (in the begining there was 0 driving for me at all - self imposed after I had 3 accidents in the course of a month with 0 prior issues). Now I'm a literal shell of what I was to the point it's embarassing and I avoid anybody who knew me. I'm not the same person - guess I have to deal with that and accept the new me.

 

[Freida]

I used to make great money, was at the top of my field, had a career that was on the fast track, and was so happy and positive - and now I'm lucky that I can drive to the psychiatrist half the time (in the begining

Yep. That was me too. Then kaaaabooooom! Whole new life :(

I'm on very few meds because I have a tendency towards bad reactions. But looking at your list? Id suggest meeting with a pharmacist and going over all of them to see how they work and why you are taking them. Why the pharmacist? Because they are trained to know how medications work - not just what illnesses they treat. We had to do that with my mom with her heart problems because the meds started cancelling each other out

Another thing I had to do was a ton of lifestyle changes...Which sucked! :laugh: yoga, acupuncture, therapt, emdr, blah blah. Remember the goal is to manage the symptoms not cure the ptsd. Which , again,
Sucks! That has been the hardest part for me - that I can't throw the "right" medication at it and make it go away.

 

[joeylittle]

I used to make great money, was at the top of my field, had a career that was on the fast track, and was so happy and positive - and now I'm lucky that I can drive to the psychiatrist half the time (in the begining there was 0 driving for me at all - self imposed after I had 3 accidents in the course of a month with 0 prior issues). Now I'm a literal shell of what I was to the point it's embarassing and I avoid anybody who knew me. I'm not the same person - guess I have to deal with that and accept the new me.

I really, really understand feeling like this. It's how I feel now as well. I'd probably replace "happy and positive" with "managing depression"...but yeah. And being embarrassed to see anyone who knew me...absolutely. It's such a shitty way to be living. You're right, there's a level of accepting where one is at - I just wanted to acknowledge that it's not easy, so try and not get too down on yourself for finding it difficult.

While I started on Trintellix the cost and lack of response moved us to Effexor especially because of it's SNRI effects. The Effexor dose was titrated up responsibly - but it's just such a high dose (375mg) and I believe above what's typically recommended in an outpatient setting. Coming off this one day is not something I try not to think about given what I've heard about withdrawal symptoms.

Jury's out on whether or not high-dose Venlafaxine is dangerous in outpatient settings - you're correct in that this dose exceeds the published guidelines, but that doesn't necessarily mean anything. It's absolutely worth discussing. I remember when I talked this through with my doc (I'm on 300mg/daily, wondered if I could go higher) he said two things - one, the more relevant question is whether the XL is clinically useful in doses above 300. Two - that there's a blood test you can get to check the active levels, which should give your doctor and you an idea of whether you're getting sufficient amounts of the active compound; apparently, there's some correlation with body mass (weight) and other factors. So, you could ask about that.

Yes - withdrawal is known to be extremely difficult. But if you can lower the dose and still get the same result, that's always a good thing to do. Worth looking into.

Combining downers and uppers every day. I understand that they work on different systems with some cross over especially in specific dopamine receptors - but lawd.

It's always good to ask about this, and personally, I think it's worth eliminating these kinds of cross-overs where it's possible. Takes some experimenting, and you want to be ready to be sick or just feel "off" - and have the time/space to do that. For me, that's usually knowing I've got a good 8-12 weeks where nothing huge is going to be hitting my plate at work. Or, I know I can take a leave or partial leave.

Anecdotal example: I'm on 300mg effexor and eventually added Vyvanse (40, then 70mg), to help counter some depression-based slowness that Effexor generally exacerbates (tried Ritalin first, it wasn't right for me). After awhile, tried stepping the vyvanse back down, but my energy and mood took a hit, so back up it went. BUT - if I don't get the vyvanse early enough in the day, I'll definitely have trouble sleeping. I'd rather work at taking it earlier or deal with missing a day, and NOT have to add something to help me wind back down. Also - when something happens and my anxiety goes up in a sustained way, I (check with my doc, but) temporarily stop the vyvanse - because it'll add to my agitation, if my system is ramped up.

You might want to - with your doc - take a look at any stimulant you're using, and see if it's still necessary to help you battle focus or energy problems resulting from depressed mood.

Last thought - if it's important for your life goals/quality of life to get off Risperidone, because of its class as an atypical antipsychotic - then make sure to tell your doctor that it's a priority for you to work towards discontinuation on that one. Have an honest conversation about it. Your current dose is low, but not sub-clinical.

A second opinion - if you can manage the logistics (cost, access) - totally worthwhile. And also, if you haven't really gotten honest with your psych about your concerns - make sure you do that, too. You'll need to know how they are thinking - and, how deeply they are thinking - about your specific situation.

One thing I know for certain is that (for those who need them), good psychiatrists are worth their weight in gold. They'll want to get the meds right, and they take seriously the fact that it's very easy to over-medicate...so they will want to know if what you're taking is effective and warranted. When there's a question about that, they'll work with you to figure it out.