Q. I have depression, anxiety, sleep disturbance with low mood. How to elevate my mood?

Answered by
Dr. Parth N. Nagda
and medically reviewed by Dr. Vinodhini. J
This is a premium question & answer published on Jul 12, 2020

Hello doctor,

I have masked depression, anxiety accompanied by sleep disturbances. I often get irritable and depressed. Other conditions are IBS and restless legs.

I am prescribed Mirtazapine 3.75 mg along with Clonazepam 0.75 mg. While I can sleep eight hours it has not improved in other parts of my life. My mood is always low and negative. Can you suggest something to elevate my mood and stabilize it so that I can switch to an active life?

I am currently on Metoprolol SR 50 one tablet, Atorvastatin 10+, Telmisartan 40 one tablet Furic Acid 40 mg one tablet, Ursodeoxycholic Acid 450 one tablet, Mirtazapine 3.75 mg, Clonazepam 0.75 mg, Coenzyme Q10, Pre and probiotics.



Welcome to

Considering your other symptoms and other medicines, I would suggest you to take tablet Escitalopram 10 mg once at night after food and raise the dose of Mirtazapine to 7.5 mg at night. The current Mirtazapine dose you are taking is a very mild sedative dose only.

It happens due to reduced levels of certain neurotransmitters such as serotonin which reduce the stress handling capacity of the brain. Medicines will help with your problem by correcting this chemical imbalance.

Treatment plan:

Tablet Escitalopram 10 mg once at night and Mirtazepine 7.5 mg daily at night.

Thank you doctor,

What to do with Clonazepam 0.75? Is it justified to start Escitalopram at 5 mg and then increase to 10 mg? If I stop Clonazepam will restless legs aggravate? If I increase Mirtazapine to 7.5 mg will it not lead to morning drowsiness?

Incidentally I have sleep apnea and suffer from daytime drowsiness and fatigue syndrome. I am not sure but that may be the outcome of low serotonin levels.



Welcome back to

Clonazepam to be reduced by 0.25 mg every three weeks. You can make four parts of this and stop taking one part every three weeks. Escitalopram 10 mg is the adult dose for depression and 5mg is pediatric dose.

If you first reduce stepwise, it should not aggravate. And if it still does there are other medicines which can be tried instead of Clonazepam since it is more addictive habit forming and will worsen your anxiety.

No, it will not increase the morning drowsiness at all. You have to take night medicines about 1.5 to 2 hours before sleeping since it takes that much time to act. And action lasts for 8 hours or so. So if you take it at say 8 PM, then you will fall asleep by 10 and wake up by 6 or 7 AM.

Just wait three weeks for the Escitalopram to take effect and then can think about something if the drowsiness and fatigue have not reduced.

Thank you doctor,

I tapered the dose of Clonazepam, reducing it gradually and I had tried with Mirtazapine 7.5 and Escitalopram 10 but I remain sleepy the whole day, but the whole night I cannot sleep. So I reverted back to Mirtazapine 3.75 + Escitalopram 5 + Clonazepam 1 mg. However, I do not have a good restful nice sleep and end up with mid of night and stay awake thereafter. My sleep apnea aggravates the cause as a lack of deep sleep leads to several arousals. The whole day I feel uncomfortable. However, with Escitalopram 5 mg, my mood has stabilized and melancholia has reduced substantially and mood swings have become lesser. However, bouts of depression still occur though frequency is far reduced.

Can you kindly adjust the dosages of my medication so that I can have a good night sleep and feel refreshed in the morning? My history with mood disorders and meditations of hypertension are in chain mail.



Welcome back to

Using Clonazepam leads to dependence. That is why its effectiveness will reduce over time and it will also aggravate your mood disorder. Hence it is better to stop it.

Also, more importantly, what time are you taking the night medicines? It is to be taken 2 hours before bedtime since they need some time to act. I would suggest you stop Escitalopram and instead switch to Venlafaxine 37.5 mg in the day time since it will help reduce your sleepiness and to continue Mirtazepine 7.5 at night.

Also additionally you can take Quetiapine 25 to 50 to 100 mg for helping you sleep instead of Clonazepam. Try first with 25 mg, then raise the dose as needed. It could be worthwhile to consider adding Lamotrigine 50 mg as a mood stabilizer since it will help with long standing depression /dysthymia.

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