Drug Combination question

Hi Cam,
First I should say I think you're a Gem for volunteering your time to ease our mind with educated knowledge. Thats very giving and thoughtful.
I used to take Paxil...and xanax during the "getting used to" period.
I am very sensitive to medications(probably a psychological thing more than a medical thing, who knows) Most people adapt to the Paxil in a week(I think?) I , on the other hand have to take 1/4 for a week...then 1/2 for another week, then yet 3/4 for one last week and finally after a month I start to balance out. The side effects are usually bad enough I spend many days fighting as hard as I can not to say "forget it" this is too much to bear. But I continue knowing from past experience it helps in the long run.
That's why this last time my Dr also gave me Xanax to deal with the side effects.
I lsot my insurance coverage back in July and no longer take the Paxil. However I had another refill for the Xanax and I also had Doxepin which he asked me to take before bed instead of xanax. (Yet ANOTHER med *sigh) This one "seemed" not to give me the bad side effects or that "hangover" feeling in the morning.
I take all medications in moderation and at the bare minimum because of my "issues" with meds and their side effects that I seem to react so easily to.
My question is...Ive had ALOT of difficulty lately with the attacks and constant edginess. I never take more than two Xanax a day and usually can go days without any meds.
For the past week or more , they have been bad and almost constant. Seems like Im always "on the edge" of a full blown attack. I also have the "tools" I learned in therapy to try and alleviate them and make them go away which for a time seemed to help, They arent now.
I am not sure the purpose of Doxepin or what it is actually prescribed for....isit ok to take it afte having taken Xanax in the evening?
Ive also been having more frequent and horrific nightmares lately too.....I wake once or twice a night already in an attack because of the intenseness of these nightmares.
Thanks for reading this lengthy post and any information is appreciated.
"Knowledge is power"
Jennifer (aka Serenity)

bumping this back up in case ya missed it the first go around

Serenity - OMG, I just spent an hour and a half replying to you for a third time. I don't know what I did the first time, my reply didn't post and I didn't realize it; the second: I stopped to have supper (it was the third time my wife had called - but I didn't hear the first two - and the cat figured out how to work the switch on the powerbar - she just had to protect us from that faint red glow!). Now, my browser quits! DOH!! That is truly heartbreaking, as well as a pain where I wouldn't put a window.

I just came off an 8 day in a row stretch at work (another story) and they haven't returned my internet computer (still another story), so I have not had access to the site. Plus, recently I haven't had the energy to think at all (haven't been this low in awhile). This may be coming too late but here goes (I've pretty much got this organized in my head by now ).

serotonin in the brain. Serotonin is one of hundreds of <A target="_blank" HREF=http://129.195.254.70/cgi-bin/HONselect?browse+D14.600#MeSH> neurotransmitters</A> (neuromodulators, etc.) that carry electrical signals (information entering and leaving the brain) from one nerve cell to another. A lack of serotonin ultimately results in the cluster of symptoms that we call depression. Serotonin is not the "cause" of depression, but we can often relieve depressive symptoms by increasing levels of this substance in the brain using serotonergic antidepressants.

As soon as you start taking a serotonergic antidepressant the levels of serotonin in the brain are increased. This is a shock to the brain; it has been running on low serotonin for some time. All neurotransmitters are linked to each other in very intricate ways; if you change the concentration of one neurotransmitter, you change the concentration and activity of them all. A brain that is functioning with low levels of serotonin is still functioning, albeit below its potential. In order to compensate for the lack of serotonin, other neurotransmitters modify (lessen) their effects on serotonergic neurons (nerve cells) and the number of receptors for serotonin increase in number.

Adding serotonin to this mix upsets this statis quo. Now the serotonin receptors begin to fire excessively due to the increased number (and possibly sensitivity) of the brain's widespread serotonin receptors, as well as the decreased regulation of serotonin by other neurotransmitters. The body now has to downregulate (decrease) the number (and perhaps sensitivity) of it's receptors, as well as adjust the concentrations of the other neurotransmitters, in order to "normalize" the flow of electrical signals through, and between, serotonergic neurons (serotontin-containing nerve cells). This takes time; the time it takes for neurons differs in different people, but usually takes between 2 and 16 weeks, (unsurprisingly) the same duration of time it usually takes an antidepressant to begin working. That excess of serotonin at the beginning of therapy results in the symptoms that I call the "start-up" side effects (eg. increased anxiety, pressure in the head, nausea, etc.).

The normalizing of the brain concentration and activity of serotonergic neurons (often) results in a resolution of depressive symptoms. Antidepressants do not "cure" depression; the original psychological problem(s) that "caused" the depression in the first place must be resolved for that to happen. Ordinarily I would make a disclaimer regarding major depressions resulting from a genetic predisposition are incurable and one must stay on antidepressant (antianxiety) medication for life. Recently I have begun to think that if researchers are able to come up with a way to decrease the brain's sensitivity to stressors that result in major depression (ie. "raise the bar" so that increased stress is needed to initiate depression - or, for those keeping score, make it harder to uncouple the HPA axis).

As for the use of Xanaxª (alprazolam) to deal with the start-up side effects of serotonergic antidepressants (like doxepin), I do recommend it in most anxiety-type disorders (panic disorder, GAD, etc.). There is no harm in using a benzodiazepine for the short term, at least until the anxiolytic activity of the doxepin kicks in.

Sorry again for the delay. - Cam

To fully understand a concept is to be unable to convey it's intricacies verbally; only when one can sense it emotionally, does one understand.

Cam,

I just want to thank you for sharing your knowledge with us here. Even when the question isn't mine, I look forward to reading your answers and have been able to understand things a lot better than I did before because of the way you explain it. You really have a gift for explaining complicated concepts in a way that makes them understandable, and you do it without oversimplifying or leaving out important information. Thank-you for sharing your talent with us.

This answer to Serenity I think helps me understand not only how taking SJW helps me (since it works in much the same way as other antidepressants), but also why I am so susceptible to getting depressed again after stopping the SJW. Even though I've gotten by for all these years without even using herbal remedies, now that I have been using SJW, my brain would have adjusted to the increased levels of serotonin caused by taking SJW by increasing production of other neuotransmitters and downregulated receptors for serotonin. So if I stop taking the SJW it would probably take some time to compensate again for low levels of serotonin. Right?

I talked about this with my T today, and that we don't know whether the low serotonin levels are a result or a cause of depression. Since I'm a psychology student, he keeps telling me it's my job to find the answers to questions like that. I'm not sure there is any more answer to that than there is to the chicken or the egg question, but it's interesting to think about it. I even find myself being interested in my own symptoms even during my depressive episodes, but even more so afterwards. It's strange, but it fascinates me in a way.

Anyway, you are appreciated probably much more than you know. Thanks for all that you have taught me so far, and I look forward to learning more from you.
Wendy

p.s. My husband is left handed and also has always been interested in history, so we just had a discussion on the word 'sinister.' He says that sinister is just the Greek word for left, and it became associated with sneakiness and evil gradually over at least the last 4000 years as the majority of people are right handed and people don't trust those who are different. Being left handed gives someone the element of surprise and can be a real advantage in situations like combat since fighting a left handed opponent requires different strategies that most people just were not used to. Also, a left-handed person could hide a weapon on their right side, as most people carried their weapons on the left and only the left side was usually searched. Left handed people could use their advantages to be very skilled as assassins. So "sinister" always meant "left" but because of the talents and advantages that being left-handed brought, and some of the ways in which those advantages were used, the word acquired the meaning that it now has.

<font color=green>"Loneliness does not come from having no people about one, but from being unable to communicate the things that seem important to oneself, or from holding certain views which others find inadmissible" Carl Jung</font color=green>

Rapunzel - The questions that I get on this site are great. I get to practice tayloring my answers for the crowd here (ie. regular people), which only helps me at work. When I have to think about what may be going in psychopharmacologically and physiologically in different cases it really helps me to understand (ie. too see in my mind) how the various medications affect the brain as a whole. If I can't describe something in plain language, I don't really understand it. Some physicist (maybe Richard Feynman?) said that if you can't fit a description of a theory on a t-shirt, then you really don't understand that theory. Nature is very simple; it's just that there's an enormous amount of these simple things. I have found that you do have to study the trees, but you must regularly step back and see how any new knowledge you acquire changes the look of the forest. If I can't see a change in the forest upon reading about a new pharmacological finding, I don't really understand the information.

If you notice, most in most of my answers I am just on "autotype". I am really just typing what I think; sort of a "flow of consciousness" thing (that's my excuse for all my spelling and grammar errors; I seldom edit ). I also like to give extra info (ie. "buts" and "excepts") over and above the question so that it may help answer similar questions other people may have.

After stopping SJW, or any serotonergic (serotonin-containing - eg. TCA, SSRI, etc.) antidepressant the body may do a number of different things, but only if the antidepressant you were taking (eg. SJW) was working. If you are taking an antidepressant, but are not getting any relief from the depressive symptoms, the neurotransmitter mix probably hasn't changed much from pre-medication times, therefore it does not need to change back. The mix should still be at compensatory levels. That is, the concentrations of the other neurotransmitters would still be at the pre-medication levels. The norepinephrine (aka noradrenaline), dopamine, et al would still be compensating for the lack of serotonin (if indeed a lack of serotonin is what is causing the depressive symptoms).

Taking a serotonergic antidepressant doesn't really do much in a person who has "normal" (non-depressive state) serotonin levels in the brain. And remember, a lack of serotonin is not the "cause" of depression, it is only an effect of depression that can explain many of the depressive symptoms. Adding serotonin by taking serotoneric antidepressants is like adding air to a tire that has a slow leak; you have to keep adding air (taking antidepressants) at regular intervals or you ruin the tire (brain).

I hope that this sorta makes sense. Sometimes my metaphors ar weird. - Cam

P.S. Thanks for the info on "sinister" guys, ..... erm, gals!