AIBU to be furious to have discovered that I'm not even on a therapeutic dose of my AD?

[Psion]

Have been struggling with depression and extreme anxiety. So have been on Trazadone for the last 6 weeks. Titrated up from 100mg, to 150mg and have been on 200mg for last week. Have also been on Quetiapine for last 2 weeks, titrated up from 50mg, to now on 75mg at bedtime and 25mg on waking.

These last few weeks have been Hell. Anxiety on waking just as severe, feeling so low and depressed with suicidal ideation constantly running in the background. Have only had a tiny handful of good days.

When I started Quetiapine, my CPN gave me an official info leaflet about it with a link to the official NHS healthcare website for my local area.

I clinked on the link today, to read that I'm fcking not even on the officially listed* therapeutic dose for Quetiapine!

It states that when being used as an adjunct for an AD the dose should be 150-300mg and should be titrated up to 150mg by Day Four (and then increased according to patient need).

It also states that when being used to treat anxiety (which I also have, quite severely) the recommended therapeutic dose should be 150mg FFS!

So, WTAF have I been suffering like the damned these last few weeks on doses which aren't even considered therapeutic??? I have looked longingly at buses and half hoped they'd run me over. I have driven past trees and wondered if I'm going fast enough to enable a fatal crash if I drive into them. There are just no words to fully describe how low I have felt.

I spoke to my CPN yesterday, and even he mused that it might well be better to increase my dose quite a bit higher, and to go in quite strong with Quetiapine, for a short time, to blat the symptoms, get some stability and then look to decrease. So, obviously he knows that I probably really should be on a higher dose!

I know they had a meds review today, but they haven't contacted me to discuss changing my dose, so I assume the doctor hasn't okayed it

I am totally confused why I have been under dosed like this. But also beyond furious. I totally get about safe prescribing etc, and can see that this is common sense.But I have told my CPN several times that it doesn't feel like the Quetiapine is even touching the sides. And no wonder, when I'm not even on the official therapeutic dose recommended on their own f*cking official website.

Just had to let rip somewhere

[DecaffCoffeeAndRollupsPlease]

When can you find out what was discussed and decided in the meds review?

[expatinscotland]

YANBU

[fedupandtired]

I'm curious as to why you've been prescribed quetiapine as its an anti-psychotic not an antidepressant. Yes, it does have antidepressant qualities and is useful for treating the depressive episodes of bipolar but I've never, ever heard of it being prescribed purely and on its own for depression.

[SaucyJack]

Objectively speaking, I do think YABU.

Quetiapine is not an anti-anxiety med, and when used for it off-label it's perfectly sensible that they experiment to find the lowest possible dose that works. It's strong stuff. It's an anti-psychotic that was designed for patients with schozophrenia and bipolar.

Sorry you don't feel happy with your care tho xx

[Psion]

I can find out first thing in the morning, by asking any of the Crisis Team, but I really want to discuss it with my own CPN as he's the actual lead CPN there, and was the one who talked about increasing my dose in the short term to sort my symptoms, then looking at decreasing.

I am concerned that the CPN who had the meds review meeting with the doctor today, was the same one who popped out to see me yesterday. Never met her before, and very much of the brusque 'Pull your socks up and get on with it' school of therapy. Got the impression she didn't much like me having an opinion and was dismissive of questions, lots of 'Who knows?' and 'How long is a piece of string' responses.

Well, maybe I would find it a bit easier to 'pull my socks up' if I was actually on an effective dose of my AD to kick start my poor brain [angry}

[fedupandtired]

But it isn't an anti-d!

[trappedinsuburbia]

I was surprised your on Quetiapine, as others have said its an anti psychotic. It may be as it is being used off label they are starting a low dose to see how you go.
You need to speak to your CPN and get a clearer explanation on whys and whatnots.
Hope you get something that works for you.

[Psion]

fedupandtired it is very commonly prescribed as an adjunct to a standard AD (I'm taking it alongside Trazadone for example). According to Google over 8 million prescriptions written for it as an adjunct to an AD in the USA last year, alone!

My CPN told me that roughly 80% of their patients take it alongside an AD, to basically boost and stabilise their mood, but obviously at much lower doses than for BPD or Schizophrenia etc. It's touted as the 'wonder drug' apparently for depression and anxiety, and is used off licence for a whole host of mental health related issues.

[Psion]

trapped it is used at much lower doses for 'standard' depression and anxiety, but according to the official NHS website these lower doses should still be 150mg to 300mg for standard depression, and 150mg for standard anxiety.

Yet I have been struggling terribly on just 100mg, and I don't understand why?

[fedupandtired]

In that case then the dosing may well be right. 300mg is the starting maintenance dose for bipolar so if you're taking it as an add-on then, as you say, it would be at a much lower dose.

My apologises - I really didn't know it was so commonly prescribed for depression alone.

[Psion]

saucyjack I completely agree with sensible prescribing. However, there is a difference between being cautious, and not actually prescribing the officially cited therapeutic dose for the medication.

The NHS website states that for my medication to be effective and therapeutic I should be on at least 150mg, rising to 300mg is necessary. Yet I am only on 100mg.

[Psion]

fedup yes 300mgof Quetiapine is the official therapeutic starting dose for Bi Polar. And according to the NHS website 150mg is the official therapeutic starting dose for standard depression/anxiety.

[shinynewusername]

Don't ask a bunch of strangers on the internet, ask your CPN about the dose. You are right that 150mg is a typical dose when used as an adjunct in depression but there are a host of very good reasons for titrating the dose up more slowly - such as concerns about drug interactions. Often, if you are titrating one drug up relatively quickly, you have to titrate others more slowly,

As you say, the MH team will have a ton of experience of using quetiapine, so it is unlikely that they have just got the dose wrong. It is likely they have done this for a reason and they should explain it to you. It is important that you feel involved in decisions about your care. Ask them whether you can now increase and make sure they realise how crap you are feeling. Hope you feel better soon

[TheGhostOfBarryFairbrother]

Argh I have been in your position... infuriating! Call your CPN in the morning and ask for an emergency appointment as well as asking about meds. If you are feeling suicidal, even passively then don't hesitate to call the crisis team. They are generally as useful as a chocolate teapot but they can sometimes get your appointment fast tracked.

Hold on, things do improve. xx

[Makesomethingupyouprick]

I'm not sure where you live (USA prescriptions are very different) but I've worked in MH in the UK for almost two decades and would query your CPN saying 80% of their patients take it in addition to anti-ds? That sounds very odd indeed.

In people I've known be prescribed it as an adjunct to anti-ds are typically (ime) prescribed low doses like yours or even lower.

[Psion]

makesomething I didn't explain myself clearly. my CPN said that roughly 80% of their patients are taking it for one reason or another, not just as an adjunct to their AD. He said it is fast becoming the 'catch all' drug for lots of mental health issues.

I do know of people taking same dose as me, or lower. But after 2 weeks on it, it doesn't feeling like it's doing a single thing, so surely it makes sense to move it up to the actual therapeutic dose now? Even my CPN thought it was a good idea to increase, and he's a grade 6 so pretty experienced.

[Psion]

GhostofBarryFairbrither did something similar happen to you?

Some on my Crisis Team are really good and encouraging (others are truly dreadful), but ultimately on a practical level all they can do is just tell you to go and have a relaxing bath or make yourself a cup of tea and watch a nice film.

[Makesomethingupyouprick]

Ah, okay that makes more sense - I was concerned that your local health authority were prescribing Quetiapine as an adjunct in 80% of depressed patients!.

Have a chat with your CPN about increasing dose but don't be cross that they haven't increased it yet. It's entirely appropriate to initiate new medications cautiously and there are potential reactions between Trazadone and Quetiapine.

You've only been prescribed Quetiapine for two weeks. As a professional, I'd do the same and be cautious so just tell your care team you don't think it's working yet and would like to discuss an increase.

[Psion]

shiny I just wanted to vent off a bit before speaking to my CPN tomorrow.

There are no contra indications as regards other meds. Though they have said it can take at least 3 weeks for the effects of Quetiapine to start to show. But it's very worrying that I'm not even on the official therapeutic dose.

[Tutu1000]

2 weeks isn't really enough time for it to be working even if you were taking it at a higher dose. I'm wondering whether how you've been feeling is due to side effects of the new medication. But do query it with your CPN. What area are you in if you don't mind me asking. I am in Hampshire and quetiapine isn't used very often for depression and anxiety. In fact I had a friend who had to have a bot of a fight to try it as they had tried so many other drugs unsuccessfully.

As for therapeutic doses they can vary between people. I have been on certain drugs before where the dr has told me they can't possibly be helping me as I'm taking below the therapeutic dose, but when they took me off them the drepression returned very quickly. So in my case a lower dose can be effective.

I hope you get your medication sorted soon so it is benefitting you, but ime whenever I begin a new medication it can take weeks before I feel it is benefitting me. The only thing that helps me immediately is diazepam.

[HopelesslydevotedtoGu]

Before getting furious I would wait to hear what the Psychiatrist has advised at your medication review.

There may be very good reasons for having you on a lower dose or titrating it up more slowly than the guidance you read recommends.

If 80% of their patients take this drug I imagine that they know how to prescribe it!

If they do say "oops, we wrote the dosage wrong", then yes you can be furious.

Whilst your CPN is an experienced CPN, they don't prescribe medication, so they won't be aware of all the relevant issues and interactions, so I would wait to hear the decision and reasoning from the Psychiatrist.

[Makesomethingupyouprick]

There ARE potential interactions with Quetiapine and Trazadone in relation to cardiac rhythm.

Even without that OP, we're talking about psychotropic drugs here which alter brain chemistry. And that can be a beneficial alteration but Quetiapine carries (as do all psychotropic drugs) side effects unrelated to cardiac abnormalities.

In years past, MH and primary care had a somewhat cavalier approach to prescribing and rapid titration. It often wasn't needed (as the individual may have responded to small doses if given the chance to respond) and was often damaging in terms of mental and physical side effects. And what happened often was the service user would have a reaction which would be seen as further evidence of their instability of mental state and another medication was added to address it and it went on and on.

The mechanism of these drugs usually takes time to show effect (as you have been told).

Your MH care providers have been sensible and caring about YOU in adding another psychotropic medication cautiously and slowly. They have been acting in your best interests and may consider an increase when you tell them it hasn't been helping yet.

I'm sorry you're struggling OP. I 'get it' , I really do but unless we're talking about hypnotic or stimulant medications, time is needed to accurately assess response and potential side effects.

[shinynewusername]

There are no contra indications as regards other meds

Well you're on trazadone so there is the potential for at least one dangerous interaction.

[EffieIsATrinket]

I'd nearly always titrate more slowly than the BNF suggests especially when prescribing psychotropic medications in the community. Have seen too many side effects happening which can put people off the medication altogether. It is very difficult to claw back any faith in the medication if this happens. There is huge variability in how people respond to quetiapine as with most drugs. If you add in nausea, extra pyramidal side effects, drowsiness etc to an already difficult situation no patient is going to thank you. Hope you find the right dose and feel much better soon.

[ImNotThatGirl]

I don't want to say YABU because you're clearly experiencing distress but I will say that there absolutely are interactions between trazadone and quetiapine. It's important to titre up slowly due and monitor that you don't have any cardiac symptoms. It isn't a serious interaction but there certainly is one. Also, quetiapine at a low dose (under 150mg) can be effective alongside other antidepressants.

Do speak to your psychiatrist and get their official advice though.