Managing Medication for Depression: Concerns and Guidance

Medication issues

Hello Dr.
Kong,
I have been taking psychiatric medication for many years, but recently I have been experiencing insomnia and low mood, with occasional thoughts of self-harm.
Currently, I have a regular follow-up appointment and am taking the following medications:
- Mirtazapine 30 mg (Luvox) at bedtime
- Clonazepam 2 mg (Rivotril) at bedtime
- Midazolam 7.5 mg (Dormicum) at bedtime
However, my condition has worsened recently, and my doctor has added medication for me to take in the morning: half of an Escitalopram 10 mg (Lexapro) tablet, which amounts to 5 mg per day.

I would like to ask Dr.
Kong:
1.
Among the three medications I was originally prescribed, Mirtazapine is an antidepressant, and I am also taking Midazolam and Clonazepam.
The addition of Escitalopram during the day, which is also an antidepressant, is this combination of medications reasonable?
2.
Since Escitalopram only comes in a 10 mg tablet, and my doctor has instructed me to take 5 mg, I am using a pill cutter, but it does not cut evenly, resulting in one piece being larger than the other.
This makes the dosage quite inaccurate, and I am concerned about the potential effects.
What should I do in this situation?
Thank you, Dr.
Kong.

Niming, 20~29 year old female. Ask Date: 2019/08/26

Dr. Kong Fanjin reply Psychiatry

Although polypharmacy should be avoided whenever possible, it still frequently occurs in clinical practice.
In your case, the combination of two antidepressants and two sedatives is considered appropriate.
The dosages do not need to be perfectly equal; slight variations are acceptable.

Reply Date: 2019/08/26

More Info

Managing medication for depression can be a complex and challenging process, especially when multiple medications are involved. Your situation highlights several important considerations regarding the use of antidepressants and anxiolytics, as well as the management of side effects and dosage accuracy.

1. Combination of Medications: You mentioned that you are currently taking Mirtazapine (an antidepressant), Clonazepam (an anxiolytic), and Midazolam (a sedative), along with Escitalopram (another antidepressant). It is not uncommon for patients with depression and anxiety disorders to be prescribed a combination of medications. This approach can be beneficial, as different medications can target various symptoms and mechanisms of action. However, it is crucial that this combination is carefully monitored by your healthcare provider. The combination of Mirtazapine and Escitalopram is generally considered safe, but it can increase the risk of side effects such as sedation, weight gain, and serotonin syndrome, a potentially life-threatening condition caused by excessive serotonin levels in the brain. Therefore, it is essential to communicate openly with your doctor about any side effects you experience and to have regular follow-ups to assess the effectiveness and tolerability of your medication regimen.

2. Concerns About Dosage Accuracy: You expressed concern about the accuracy of your dosage when cutting Escitalopram tablets. It is understandable to worry about taking an imprecise dose, especially when managing a mental health condition. While some medications can be safely split, others may not be suitable for this practice due to their formulation or the way they are absorbed in the body. Escitalopram is often available in a liquid form, which may provide a more accurate dosing option if cutting the tablets is problematic. I recommend discussing this concern with your doctor. They may be able to prescribe the liquid formulation or adjust your dosage in a way that does not require cutting the tablets. Additionally, if you find that the 5 mg dose is not effective, your doctor may consider other options, such as prescribing a lower dose of a different medication or adjusting the timing of your doses.

3. Managing Side Effects: It is important to monitor how you feel on your current medication regimen. If you are experiencing increased symptoms of depression, insomnia, or suicidal thoughts, it is critical to reach out to your healthcare provider immediately. These symptoms can indicate that your current treatment plan needs to be adjusted. Sometimes, the introduction of a new medication can lead to temporary side effects or an initial worsening of symptoms before improvement occurs. However, if these symptoms persist or worsen, it is essential to have a conversation with your doctor about alternative treatments or adjustments to your current medications.

4. Psychotherapy and Lifestyle Modifications: In addition to medication, consider incorporating psychotherapy into your treatment plan. Cognitive-behavioral therapy (CBT) and other forms of talk therapy can be highly effective in managing depression and anxiety. Furthermore, lifestyle modifications such as regular exercise, a balanced diet, and good sleep hygiene can also support your mental health and enhance the effectiveness of your medications.

5. Emergency Situations: If you ever feel overwhelmed by suicidal thoughts or feel that you may harm yourself, it is crucial to seek immediate help. Contact a mental health professional, call a crisis hotline, or go to the nearest emergency room. Your safety is the top priority.

In summary, managing depression with medication requires careful consideration of the medications used, their dosages, and the potential side effects. Open communication with your healthcare provider is essential to ensure that your treatment plan is effective and safe. Don't hesitate to voice your concerns and seek adjustments to your regimen as needed. Remember, you are not alone in this journey, and there are resources and support available to help you navigate your mental health challenges.

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