Max diazepam dosage

[johnep]

Rereading your posts, consider more likely to be mild depression than anxiety. If you tend to wake up around 4am and worry about the world, then that is a strong pointer to depression. If so then citalopram or floxetine would be more appropriate.
johnep

[bobbin]

I'm currently doing CBT now, judging by the long term remission rates though I'm certainly not relying on it and need a pharmacological backup, even if it's something that's limited to once a week or so due to tolerance. There are a few medications I've tried that immediately alleviate my anxiety like Xyrem and Dexedrine but they are not available on the NHS unfortunately, even widely used antidepressants like bupropion and tianeptine are't available on the NHS which is why I've been trying to find a private psych.

2mg of diazepam is a low dose, yes. Due to the risk of dependence, the current tendency in the UK is to stick to very low doses; although such doses may be ineffective in many cases....and therefore valueless. In the UK, the maximum licensed dose for severe anxiety is 30mg per day. In the US, the maximum licensed dose for severe anxiety is 40mg per day in divided doses.

However........... the fact that you did not respond to a single dose of 20mg demonstrates that diazepam is very unlikely to be an effective treatment for your anxiety at any dose. Rather than considering more potent benzodiazepines, I would recommend looking into non-benzodiazepine alternatives.

As you already know, bupropion (Wellbutrin) is very widely used in the US an an antidepressant. It is not generally used to treat anxiety. In fact, some patients find that bupropion makes them feel quite agitated. Bupropion is preferred by many depressed patients due to the absence of sexual dysfunction and weight gain - which are common side effects of other antidepressants. In the UK, bupropion is licensed only for smoking cessation. The brand name is Zyban. A psychiatrist could prescribe Zyban off-license if they wished to do so. It is their clinical decision and their responsibility.........but it's not normally used for SAD anyway so moving on......

Tianeptine (Stablon) is an antidepressant which was developed in France by Servier Laboratories. It has never been licensed in the UK........ (not that there's anything wrong with it, I don't think Servier has ever applied for a UK license). Tianeptine has not received much study for anxiety.

In terms of medication, Social Anxiety Disorder is normally treated with an SSRI, if symptoms are severe. Escitalopram (Cipralex, called Lexapro in the US) is licensed specifically for SAD, although similar drugs such as citalopram are also suitable. It often takes about two months before anxiety is alleviated. SSRIs can be combined with psychological treatments, if appropriate.

Very severe cases of SAD can be treated with phenelzine (Nardil). Nardil can cause considerable side effects and requires dietary restrictions but it can be very effective for some patients who are disabled by severe anxiety when other treatments have failed. Nardil is normally only used by consultant psychiatrists who specialise in the treatment of anxiety disorders.

Amphetamines (Dexedrine) and GHB (Xyrem) may give you a short-term confidence boost but it ought to be clear that neither of them are appropriate for long-term treatment!!!

Bobbin

[LeftArm]

I'm just your typical teenage comp sci student, I have an interest in psychopharmacology

Go back to your GP

[Ashley]

2mg of diazepam is a low dose, yes. Due to the risk of dependence, the current tendency in the UK is to stick to very low doses; although such doses may be ineffective in many cases....and therefore valueless. In the UK, the maximum licensed dose for severe anxiety is 30mg per day. In the US, the maximum licensed dose for severe anxiety is 40mg per day in divided doses.

However........... the fact that you did not respond to a single dose of 20mg demonstrates that diazepam is very unlikely to be an effective treatment for your anxiety at any dose. Rather than considering more potent benzodiazepines, I would recommend looking into non-benzodiazepine alternatives.

As you already know, bupropion (Wellbutrin) is very widely used in the US an an antidepressant. It is not generally used to treat anxiety. In fact, some patients find that bupropion makes them feel quite agitated. Bupropion is preferred by many depressed patients due to the absence of sexual dysfunction and weight gain - which are common side effects of other antidepressants. In the UK, bupropion is licensed only for smoking cessation. The brand name is Zyban. A psychiatrist could prescribe Zyban off-license if they wished to do so. It is their clinical decision and their responsibility.........but it's not normally used for SAD anyway so moving on......

Tianeptine (Stablon) is an antidepressant which was developed in France by Servier Laboratories. It has never been licensed in the UK........ (not that there's anything wrong with it, I don't think Servier has ever applied for a UK license). Tianeptine has not received much study for anxiety.

In terms of medication, Social Anxiety Disorder is normally treated with an SSRI, if symptoms are severe. Escitalopram (Cipralex, called Lexapro in the US) is licensed specifically for SAD, although similar drugs such as citalopram are also suitable. It often takes about two months before anxiety is alleviated. SSRIs can be combined with psychological treatments, if appropriate.

Very severe cases of SAD can be treated with phenelzine (Nardil). Nardil can cause considerable side effects and requires dietary restrictions but it can be very effective for some patients who are disabled by severe anxiety when other treatments have failed. Nardil is normally only used by consultant psychiatrists who specialise in the treatment of anxiety disorders.

Amphetamines (Dexedrine) and GHB (Xyrem) may give you a short-term confidence boost but it ought to be clear that neither of them are appropriate for long-term treatment!!!

Bobbin

I know that SSRI's are the standard treatment, but the long term efficacy is not confidence inspiring, and the side effects like anhedonia, fatigue and sexual dysfunction are concerning along with the withdrawal after discontinuation, non selective MAOI's are out of the question. I don't really want to be on the antidepressant merry-go-round or under the influence of psychoactive medications 24/7 attempting to artifically improve my mood and simply masking the problem, short acting drugs that can help me with CBT exposure are more preferable for me at the moment. Anyway thanks for the info on licenced dosages, looks like I'll have to wait to see the psychiatrist.

[bobbin]

I know that SSRI's are the standard treatment, but the long term efficacy is not confidence inspiring, and the side effects like anhedonia, fatigue and sexual dysfunction are concerning along with the withdrawal after discontinuation, non selective MAOI's are out of the question. I don't really want to be on the antidepressant merry-go-round or under the influence of psychoactive medications 24/7 attempting to artifically improve my mood and simply masking the problem, short acting drugs that can help me with CBT exposure are more preferable for me at the moment. Anyway thanks for the info on licenced dosages, looks like I'll have to wait to see the psychiatrist.

To be honest Ashley, there aren't any short-acting drugs apart from benzodiazepines that a psychiatrist would prescribe. Since you do not appear to respond to benzodiazepines, you have a choice between long-term medication (eg. with an SSRI) or no medication. CBT can be effective (if you can actually get a decent course of treatment without waiting for months).

With regard to SSRIs, treatment for one year (or so) can often allow patients to get enough experience of coping with difficult social situations to come off the medication. Whilst on the SSRI, you would need to get out and meet people. If you stay at home on the computer you may not experience much benefit! Withdrawal should then occur gradually over a period of a few months.

Bobbin

[johnep]

As usual, Bobbin knows best. Perhaps pt could consider becoming a pharmacist as he/she has such an interest in meds. The whole story of psychotropics is fascinating and the background is relevant to all. Modern drug usage had barely started when I qualified and I watched the developments with great interest.
johnep

[bobbin]

Perhaps pt could consider becoming a pharmacist as he/she has such an interest in meds. The whole story of psychotropics is fascinating and the background is relevant to all. Modern drug usage had barely started when I qualified and I watched the developments with great interest.
johnep

True. But I would advise not mentioning the GHB (Xyrem) at the interview

[Ashley]

As a bit of an update I'm on buspirone now, 30mg/day, the private psychiatrist said that it's fine for long term use upto 60mg/day despite what the BNF says about short term use. Also trying clonazepam 3mg prn currently, titrating up the dose, no effects as of yet but she said she is fine with trying others such as lorazepam and alprazolam and that there can be a huge difference in response to the different chemical classes of benzodiazpines. Best of all she has no problem prescribing agomelatine and the other AD's I mentioned without trying SSRI's. The NHS psyhiatrist said she couldn't prescribe anything other than trazodone or mirtazapine before trying ssri's due to NICE guidelines....

[johnep]

Have you thought just how important your 'condition' has become to you? secures lots of attention etc. Perhaps you have got into a cycle of treatment
etc and have become somewhat obsessive. Psychoanalysis could be helpful.
johnep

[bobbin]

As a bit of an update I'm on buspirone now, 30mg/day, the private psychiatrist said that it's fine for long term use upto 60mg/day despite what the BNF says about short term use. Also trying clonazepam 3mg prn currently, titrating up the dose, no effects as of yet but she said she is fine with trying others such as lorazepam and alprazolam and that there can be a huge difference in response to the different chemical classes of benzodiazpines. Best of all she has no problem prescribing agomelatine and the other AD's I mentioned without trying SSRI's. The NHS psyhiatrist said she couldn't prescribe anything other than trazodone or mirtazapine before trying ssri's due to NICE guidelines....

Hi Ashley,

Buspirone is normally used for a few months or long term. There doesn't seem to be any particular problem with using it for prolonged periods and it does not cause dependence.

Take care with clonazepam. 3mg is actually quite a lot. Clonazepam is a very potent benzodiazepine and dependence can occur rapidly. Clonazepam is normally effective for panic/anxiety at lower doses eg. 0.5mg twice a day. If it isn't working at 3mg it might be best to try something else.

Since the psychiatrist is private, I assume you are paying for private prescriptions. Agomelatine is pretty expensive! It might cost you more than your appointment.