Balancing The Need For Benzos and Antidepressants To Cover Anxiety

I noticed another fellow talked about being on 3 mg on klonopin for 15 years. For me, it’s been about .5 to .75 mg per day for 14 months but I have still been unsuccessful coming off of it. Do you recommend using acupucture and meditation during a slow taper? I also take 60 mg. of celexa. Should I ask my psychiatrist to put me on an SSRI that is stronger or at least different to help with my k-pin weaning?

When I read your question . . . my head is filled with . . . why . . why . . . WHY????

Why did you go on the Celexa?  Why is the Celexa dose 50% higher than the typical maximum dose? Why go off the Klonopin?  Why have you been unsuccessful coming off?  Much of the answers to these questions centers on why you are on the medicine you are taking.  I must take some liberties and assume some facts here.  I will assume that you had a primary diagnosis of Major Depression that was accompanied by some anxiety.  I will assume that you got good resolution of your symptoms with the above medicines.  I will assume that you are tired of being on so much medicine and now want to wean off.  As I look at the regimen you take, my concern is not that you are on the Klonopin, but that the dose of the Celexa is so high.  Why is that?  There are certainly times where that aggressive approach is warranted, but not usually.  Too much of an antidepressant can, at times, precipitate MORE anxiety and feelings of edginess.  That could, perhaps, be at the root of your difficulty getting off the Klonopin.  If you are stable and doing well on the medicine, the first step might be to lower the Celexa down to a normal dose and then try to titrate off the Klonopin.  I will also remind you that some people just do better on Klonopin.   The doses you are using are modest, so unless you have a particular reason to come off (getting pregnant, wanting to drink alcohol, etc), there is no specific reason that you MUST come off.  I shy away from the view that Klonopin is a “bad” medicine that must be minimized at all costs.  It’s badness is really dependent on how the person taking it uses it.

Another factor that must be considered is what is your diagnosis.  If you had a strong history of anxiety before you had Depression (or developed it as part of the depressive complex), it could be that you will have persistent depression that could be addressed with medicine.  Sometimes the antidepressants work alone to do this, sometimes we NEED to use benzos.  While most antidepressants will work for most people, some do respond better to one than they do to another.  No way to predict this.  You mention a “stronger” antidepressant . . . ain’t no such thing.  It is not about one being stronger or weaker.  It is just about one working better for YOU.

Here is what I’d suggest.  First, have a planning session with your doctor about what you want to do and why.  Get him to outline steps to take and then you must stick to those steps without fail . . . or at least make no changes without re-consulting him or her.  It sounds like your primary desire is to get off the Klonopin.  Any taper should be exceedingly slow since you have been on the medicine for a long time.  I would go down by no more than .25 mg every month.  Your antidepressant dose should be no more than the maximum recommended dose (to avoid overstimulation).  If you cannot reduce the dose of Klonopin without getting anxious, put the dose back to the last comfortable dose.  You can then switch to a different antidepressant (the choices are many and you would have to work that out with your doc).  Once you are stabilized on the new antidepressant, try to wean down on the Klonopin again . . . very slowly.

Ultimately, if your experimentation leads you to conclude that the Klonopin is a must to keep you from feeling anxious, you must decide if you really need the antidepressant.  If the Klonopin is needed for anxiety, the only reason for the antidepressant is for depression OR to help keep the dose of Klonopin down.  You might, in the long run, do quite well with only a  low dose of Klonopin on board.  In any case, you will need to be patient.  You have been on the medicine for a long time and getting these adjustments made might take many months or even a year or more to figure out.  Work out with your doc your ultimate goal and stick to slow methodical steps toward this goal.

–Dan Hartman, MD

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