Dr. Saraswat Kumarshri Shriniwas
Psychiatry
The following is an actual conversation between an iCliniq user and a doctor that has been reviewed and published as a Premium Q&A.
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Patient's Query
Hi doctor,
I am taking tablet Lexapro (Escitalopram) 15 mg and tablet Flupenthixol 5 mg for stress and anxiety for the last six years. If I stop tablet Flupenthixol, the images and situations of people with whom I got into arguments or fights come to my mind, and I cannot get rid of those thoughts. Also, I become sensitive and tend to ruminate a lot about small negative situations that have happened. As tablet Flupenthixol is sedating, I have to sleep for 12 hours, without which I get a headache. Right now, I am married and cannot sleep like that due to responsibilities. During my bachelor's life, I could sleep for 12 hours easily. I had a discussion with my treating doctor about the sedation of tablet Flupenthixol. He said it is a weak sedative (maybe 10 to 15 percent). On top of that, he has prescribed only the lowest dose (5 mg). He also informed me that, most probably, you will have the same issue with other antipsychotics as well. But I am sure that it is causing the sedation because when I was on 5 mg of tablet Flupenthixol on alternate days, without any effort from my side, I woke up without any issues after sleeping for seven to eight hours. But again, due to stress in my profession, I was put back to 5 mg tablet Flupenthixol daily. Apart from mild cholinergic and histaminergic action, is there any other reason why tablet Flupenthixol 5 mg is causing sedation? Does antagonism of the dopaminergic system, or the serotoninergic system causes sedation? Can you suggest an alternative for tablet Flupenthixol? I heard that there is a non-addictive benzodiazepine called tablet Etizolam. Can I use it for the long term?
Hello,
Welcome to icliniq.com.
I suggest the following medications (consult with a specialist doctor, talk with him or her and take medicines with their consent). Tablet Flupenthixol in low doses (0.5 to 1 mg) is prodopaminergic, which improves dopamine neurotransmission. At 0.5 mg, it is actually activating or alertness-promoting. It is preferably given in the morning for such a dose. Why you are feeling sedated could be your metabolism (a low dose also has a bigger effect), or maybe combining it with tablet Escitalopram is having this effect. Also, individual responses to each medicine regarding sedation could differ vastly. What one finds alerting could make another drowsy all day. Tablet Etizolam is a sedating benzodiazepine (most people will sleep more on tablet Etizolam than tablet Flupenthixol). It is non-addictive and can be used in the longer term. There is a controlled-release version that some might find less seating. You describe obsessive imagery and increased anxiety about stopping tablet Flupenthixol. In such situations, I usually suggest tablet Fluvoxamine or tablet Fluoxetine over tablet Escitalopram. Maybe changing tablet Escitalopram with tablet Fluvoxamine could obviate the need for tablet Flupenthixol. A couple of dopamine-modulating medicines act like tablet Flupenthixol, but the individual responses in terms of sedation cannot be predicted. These are tablet Aripiprazole at a dose of around 1 mg and tablet Amisulpride at a dose of 25 mg.
Patient's Query
Hello doctor,
Thank you for the reply.
I was taking tablets Flupenthixol 0.5 mg and Escitalopram 10 mg at bedtime. Lately, my tablet Escitalopram dosage was tapered from 15 mg to 10 mg. Based on my experience, I am getting 70 percent of relief from the tablet Flupenthixol 0.5 mg. The first choice of the doctor was to put me on a tablet of Escitalopram 15 mg and see if I was stable on that. But there was not much improvement. The moment tablet Flupenthixol 0.5 mg was added, there was a great relief, and I became stable. I tried taking tablet Flupenthixol 0.5 mg in the morning and tablet Escitalopram 10 mg at night, but drowsiness (feeling not refreshed after sleep) remained the same. I am ready to try tablet Amisulpride, tablet Aripiprazole, or tablet Fluvoxamine. Do I need to switch to tablet Fluvoxamine immediately and see if that works? What are your thoughts? I know it is an SSRI (selective serotonin reuptake inhibitor), but does it improve dopamine transmission or another neurotransmission apart from serotonin?
Hello,
Welcome back to icliniq.com.
I would suggest making drug changes after discussing with your treating doctor because they know your detailed history and are available for emergencies. Switching from tablet Escitalopram to tablet Fluvoxamine, you need not taper. You can stop taking tablet Escitalopram and start taking tablet Fluvoxamine the same day. Tablet Fluvoxamine has sigma receptor agonist action in addition to being an SSRI (selective serotonin reuptake inhibitor). That makes it more useful in OCD (obsessive-compulsive disorder) spectrum disorders (intrusive images or thoughts).
Patient's Query
Hello doctor,
Thank you for the reply.
I took tablets Escitalopram 10 mg and Flupenthixol 0.5 mg at night, which made me sleep for 12 hours, without which I did not feel refreshed. You have pointed out that tablet Flupenthixol has alert properties at a low dose, so I took it in the morning and tablet Escitalopram 10 mg at night, and I did not feel good response. Another possibility was that the combination might cause sleep issues. So I avoided tablet Escitalopram 10 mg for one week and found this.
Hi,
Welcome back to icliniq.com.
Many a time, what seems like a sleep issue might actually be a mood issue. We gauge quality of sleep based on how we feel in the morning. If we feel fresh, we think we slept well. If we do not feel fresh, we think the sleep was inadequate or poor quality. Feeling unfresh, cloudy and headaches might be a symptom of depression. My advice would be, rather than going for a sleep aid, go for an anti-depressant medication. If you are looking for a sleep aid which increases depth of sleep, tricyclic antidepressants like tablet Amitriptyline, tablet Imipramine, tablet Nortriptyline, tablet Dosulepin increase the quality of sleep in addition to their anti depressant effect (consult with a specialist doctor, talk with him or her and take medicines with their consent). Another option is tablet Pregabalin or Gabapentin which increases the deep sleep but do not have anti-depressant effect.
Patient's Query
Hello doctor,
Thank you for the reply.
Is it fine to take combination drugs like tablet Escitalopram 10 mg, tablet Flupenthixol 0.5 mg and tablet Amitriptyline 25 mg? What does the medical literatures says about cannabis? I see that some people use it for medical purposes like pain relief and sleep. What is its addictive potential, when compared with alcohol?.
Hi,
Welcome back to icliniq.com.
The combination is fine. Cannabis does not have physical withdrawal symptoms unlike other substance of abuse. So likelihood of dependence or addiction is low as compared to alcohol or other drugs. Cannabis in susceptible individuals or in higher doses can cause or precipitate psychosis, a major adverse effect. Secondly after prolonged use in higher doses, it can cause amotivation syndrome (reduced drive to do anything creative or productive). Besides, it is a gateway drug. People start with cannabis and move on to harder drugs.
Patient's Query
Hi doctor,
What is your opinion on Flupenthixol 5 mg and Melitracen 10 mg combination instead of Flupenthixol 5 mg and Escitalopram 10 mg? What about the safety and tolerability profile in the medical literature? Can it be used in the long term? Why is this drug not used as commonly in other countries as other TCAs?
Hello,
Welcome back to icliniq.com.
Melitracen is a TCA (tricyclic antidepressant) closely related to Amitriptyline. However, not much is known about its pharmacology due to limited studies. Physicians commonly use Flupenthixol and Melitracen combination, and gynecologists and general practitioners for somatic symptoms like backache, irritable bowel syndrome, and headache associated with mild anxiety and depression. It is a decent drug when symptoms are of mild intensity. However, treating moderate to severe depression on its own is not adequate. It is pretty safe and usually well tolerated. However, some patients take it for long-term use without significant side effects. Escitalopram, in comparison, is well well-studied and proven antidepressant and anti-anxiety agent, even in moderate to severe cases. Melitracen is less used as it is not a well-studied molecule. Besides, there are not many studies to prove its efficacy in depression. Also, fixed-dose combinations (with unclear mechanisms of action) like this are banned in many countries. Hence it is not used as much as other TCAs. One difference is Melitracen is not sedating, unlike other TCAs. So, Flupenthixol and Melitracen combination is also taken in the morning.
Patient's Query
Hi doctor,
When Flupenthixol 5 mg interferes with sleep, some doctors prefer Melitracen 10 mg and Flupenthixol 5 mg. What is the idea behind this? Does it improve sleep like a sleep aid, or does it negate the effects of Flupenthixol on rest? What are your thoughts on this? Are there better alternatives for Melitracen 10 mg?
Hello,
Welcome back to icliniq.com.
Melitracen is also activating like Flupenthixol. Hence the combination of the two is given in the morning. It does not act like a sleep aid or negate the activating properties of Flupenthixol. However, anxiety and depression are both associated with sleep difficulties like insomnia, sleep breaks, and poor sleep quality. If the combination is effective in treating anxiety and depression, then indirectly, it will also help with sleep (which was poor due to stress and depression). There is no exact alternative to Melitracen since it is a TCA. So, I suggest trying another TCA instead of Melitracen.
You can classify them as,
Any of the above at a 25 mg dose can be an alternative to Melitracen.
Patient's Query
Hello doctor,
Your diagnosis the sleep trouble (nonrefreshing sleep, light headache). I have is due to depression is right on point. Along with Escitalopram 10 mg (morning) and Flupenthixol 0.5 mg (morning ), I have started taking Nortriptyline 25 mg (morning) and 25 mg (night) for the last two weeks. I would say that I am feeling much better (I can rate the improvement as 75 %). Another option I got from my treating doctor was to stop Flupenthixol which I refused as stress will come back with vengeance. Why is Flupentixol interfering with sleep? Is it because Flupentixol down-regulates serotonin and Norepinephrine or any one of them? I understand that Flupentixol has the potential to down-regulate norepinephrine and cause motivation. I have experienced the same with 1.5 mg in the past.
Hello,
Glad to know that our conversation has helped you and you are feeling a lot better.
Flupenthixol is a dopamine antagonist primarily. At low doses, it could be Activating but it depends from patient to patient (different pharmacokinetics and brain dopamine receptor densities). In your case, it seems that even at 0.5 mg, it is causing dopamine receptor blockade and hence reduces dopamine neurotransmission. This explains its effect on sleep. There are no significant direct effects on serotonin or nor epinephrine. The dopamine blockade could also cause motivation.
Patient's Query
Hello doctor,
One more option I received is Modafinil 200 mg (morning). I have a sensitive stomach. I started at 100 mg. The heartburn I got is horrible. For such a heart burn I have to be on a Proton Pump Inhibitor 3 times a day. Nortriptyline is much better (I take PPI once every day). May I know your opinion on Modafinil vs. TCA for sleep issues? Since TCA is helping with my sleep, I guess it is enhancing dopamine transmission indirectly. After staying on Nortriptyline 50 mg for a couple of months, is it possible to taper it to 25 mg so that I can avoid night time dose?
Hello,
Welcome back to icliniq.com.
I prefer TCAs because modafinil causes restlessness, agitation, and mood instability at times. TCAs also improve deep sleep which is beneficial. Yes, it is helping you with sleep and depression. So, it will improve dopamine neurotransmission as well. Yes, it is possible to taper the dose after some time. Some people are comfortable with 25 mg but some people need higher doses. It is not possible to predict in advance, who will need more for maintenance.
Patient's Query
Hello doctor,
Sorry for bothering you again. My current medication is Escitalopram 10 mg, Flupenthixol 0.5 mg, and Nortriptyline 25 mg for sleep quality issues due to Flupenthixol. I have rated my improvement as 75 % last time. For the last 1 month, I do not have a problem with sleep quality. I feel refreshed after sleep. I sleep 7 to 9 hours easily in a day after the addition of Nortriptyline. 25 % of the nonimprovement is related to the eye. When I look at the monitor, I feel a sensitivity towards it. It is like I am not comfortable with the brightness or the light from the monitor. I have reduced the brightness and contrast of the monitor. I am using an anti-glare and blue light filter spectacle. But that is not helping. I do not have this problem while looking at my mobile phone screen. For the last 10 years, I have been working with a computer monitor. I can remember that this problem started when Flupenthixol started causing sleep issues. But this is not going away even after the addition of Notripytyline and sleep quality has improved in the last month. Is it because my eyes are not properly rested after sleep? Do I need to refer an eye specialist?
Hello,
Welcome back to icliniq.com.
Good to know that your sleep and mood issues are settled. Regarding your eye, it could be photosensitivity/photophobia dry eyes, or both. My first advice would be using an appropriate size OLED monitor which comes with eye care or reading mode. Keep it a proper distance too (not too close). Read about the 20-20-20 rule about looking at a computer screen on the internet to help with eye strain. There are no definitive medicines for photosensitivity. Magnesium supplements are known to help with it. For dry eyes, it is better that you consult an eye specialist, but some things which you can do are. Take a vitamin E supplement like Evion 400 mg daily. It helps in keeping the eyes moist. Artificial tear drops 3 to 4 times a day for 6 weeks are also indicated and relieve the distress immediately.
You might need antibiotic eye drops, ointment if the tear glands at the eyelid are affected. This will require a proper evaluation by your eye doctor.
Hope this helps.
Patient's Query
Hello doctor,
I went to an eye hospital and they gave me teardrops and one anti-allergic drops to be used for 20 days. I could say that 60 % of the issues are resolved. But they have to mention anything about vitamin D checks. I would like to do a vitamin D check. When I consulted a laboratory they said that there is a D and D3 check. Which one should I choose? I remember a couple of years back when a full blood check was done, the vitamin D level was below normal.
Hello,
Welcome back icliniq.com
Good to know that you consulted an eye specialist and that your eye issues are better. A 25 hydroxy cholecalciferol (vitamin D). Is the most accurate test for measuring your vitamin D stores. If your levels are low, then a supplementation could help you with your eye strain as well.
I hope this has helped you. Thank you.
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Psychiatry
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