Venlafaxine + Mirtazapine + Olanzapine... too much now?

[JoeyLin]

My mum suffers depression (stays in bed if she could, needs pushing to do her normal activities - cooking, self cleaning, no motivation to do anything unless made to) and huge levels of anxiety (paces around before upcoming decisions / events, talks to herself, cries whilst doing stuff).

However, 'in the moment', and when dropped into a situation which involves interaction (e.g. meeting relatives, going to an event, going to a wedding)... She DOES have the ability to behave somewhat 'normally' , e.g. communicates well, acts appropriately according to how she was previously (2 years ago now). But with short bursts of anxiety every few minutes.
She would never opt to do any of these things for herself, even if it means missing grandchildren's birthdays etc. (thats the bit that makes it very sad).

So after initially being on Sertraline a couple of years ago and not getting anywhere. Then Mirtazapine alone.

She is now at a point she is on 30mg Mirtazapine, 150mg Venlafaxine, and 5mg Olanzapine (Consultant did believe she was masking pychosis previously especially with the pacing around).

We went to consultant today and mum can now sit and have a nice chat. When convo goes quiet, she will have brief moments of panic / anxiety, where she looks to get up. but in a convo again and she can relax again.

We were hoping that medicines should be reduced.

Instead consultant has increased Venlafaxine to the max of 225, said the olanzapine has 'anti anxiety affects in the combination' AND also given Lorazapam for short term she can take before going through something anxious.

I'm not sure what to do??

Any advice on this detailed scenario?

Problem with having lorazapam during anxiety is that she herself will never choose an activity, so it will be for family members to determine. Which just means we'll be feeding more medicines to her.

I can't see why Olanzapine is still necessary.

Hi OP I'm also on long term 5mg low dose olanzapine, along with fluoxetine. they told me the same.

Why is it a worry to you? With me I worry as it can make me crave carbs and sweets. Not sure if your mum gets that with it.

If you look at NICE guidelines GP should monitor your mum's bloods on this for e.g. blood sugars and cholesterol. It is very low dose though.

I have just been put on Pregabalin to add to the mix. This is for pain though but apparently can be used for anxiety.

I think it is good your mum is getting (and is willing to see) a specialist, being compliant and consistant with meds can be important.

Just an opinion from someone in the same boat as your mum. Maybe I sound a little defensive, my DH can seem a bit anti meds at times and seems to always want me to reduce or come off them.

This can make it feel like you are failing or using them as a crutch but sometimes it is not that simple.

Maybe give it a go and see how it works out and then go back if it doesn't. At least it has been tried.

@Orangesandlemons77 - thank you for taking the time to read and reply.
Mum is a bit anti-meds, but she always just says that but is compliant. She does sometimes need reminding though to take it, which again is hard to see from how reliable and dependable she was.

I just thought 4 different tablets could be made more efficient.

We did think potentially the 5mg of Olanzapine could be holding her back in her development, but Dr seemed so confident.

We (via research) and her CPN did question the Olanzapine.

There's somethig about combing it with antidepressants that they seem to like. I first had it with mirtazapine and it caused a lot of drowsiness and weight gain. So that is something to watch for. Sometimes they don't tell you all the side effects. The mental ones perhaps but not the physical. I had to ask for the yearly health / blood tests.

Yes, mum seems to have some cravings as I find her in the cupboard often. Once she came to my house and I offered her some Cadburys heroes. After a while I heard her rustling in my kitchen where they were kept. We found it so cute!! Because usually she doesnt take anything without asking.

But yes, Dr is aware her meds are on the 'max for her age', especially now the 225mg of Venlafaxine. We will push for health checks.

However we have no issue with her eating more. Anything that gets her out of bed , as a sign of self care or self fulfillment is a MASSIVE deal to us.

Can you keep a diary of how your mum is? This will help you see if there actually is an improvement with the new doses and with the addition of Lorazepam.

Also, if you are worried about her remembering to take the tablets, could you set up an Alexa/Google Home / Siri to remind her? I'm on Mirtazepin and medication for other issues and I couldn't cope without my reminders, even with both DH and DD helping.

Tbh, the fact that your mum is actually getting to see a consultant and CMN is amazing. And you sound like a caring daughter.

Just to add , the increase of things drugs may give your mum heightened anxiety for a while until they settle

its good your trying to involve your mum in activities but please don’t push her so she feels so out of her comfort zone as this will set her back.
little & often
maybe a walk round the block,park
a trip to the small shop
in the garden (when warmer)
does she like reading ? Library
colouring books

I got the health checks by printing out the NICE guidance for antipsychotics, and giving it to the GP. It may be the MH trust to do it in your case though.

Hi new responders... Yes, we keep a log of her, its important as she has changed medicines and doses so much over the last 2-3 years. There are changes. Up and Down every month or so.

2 years ago she was Can't do it, Won't do it..
Now she is Can do it, but won't do it.

i.e. she has proven she can interact 'almost normally' in social settings. She has been MADE to go to events and been OK when parachuted into situations. . She has just been on a 10 day trip to India where her brother lives for her nephews wedding. Now it was a tough call to take her. She resisted, became heavily anxious beforehand and didn't take it seriously. But from the Airport onwards she got better and better there each day. Imagine from being in bed for almost 2 years to being in your birth village with people swarming you like you're royalty. I felt her strict brother could have fixed her up within 2 months. but she came back with me after 10 days.

Then for a week she spent in bed, it was heartbreaking. Now she is on iPad watching highlights from the wedding events and showing dad who is who.

Its like we all live day by day to see what she is like. It hurts, and then we cling on to any bit of hope we find.

We just need her to start doing things herself, for herself, and for others. Because she has proven she isn't incapable.

@Seasider2017 - i'd love to get her sowing and knitting. Again, being in India, family were suprised by her lack of shopping or interest in suits and sowing them for others. And yes she likes gardening.

Apologies the "I felt her strict brother could have fixed her up within 2 months", is tongue and cheek as I re-read my post and don't want that to be misconstrued. Her mental illness is real.

Just a thought do you think you do too much for her? and she’s Nit helping herself?
ie. Bring her drinks , food etc like she just sits/lies there waiting for it ?
I know you say you push her, when you do push her to do thing’s especially outside shopping etc
how does she react? Can you see she’s anxious
many panic attacks happen? Does she ever say “ I’ve got to get out off here ?

is she still doing daily tasks herself without being told/helped ie cooking,washing cleaning
just going for shower doing her hair maybe
whats her concentration span like ?
does she get frustrated,angry at anything

you say this is 2 yrs now, how old is your mum?
is see menopause age?
if so, get her hormones checked from gp
dont be fobbed off if she’s of that age there very very important your hormone levels in relation with depression/anxiety and lack of them
also has she had a full thyroid blood test also another imbalance that can have affects on your health.

so for all the questions, it’s just no gp or psychiatrist ever mentioned this stage of life to me and because I was so poorly at the time never entered my head.
I went through hell changing my meds onto venlafaxine and getting it fairly level so I could get some interest in things back and lower my anxiety. I’ve always suffered anxiety since in my 20’s
instead of changing depressant I think they should off tried me with HRT first
just mentioning as this can be overlooked

Yes I agree they can sometimes not look at the bigger picture, letting the psych be in charge of the meds etc

Another thing could be has she any psychologist or counselling input?

Might be useful to look at anything underlying, you mention she seemed to improve in India, could it be being away from family is making it worse?

Could something to do with India help e.g. a group for others / Indian cooking course, something like this perhaps? (apologies if insensitive, just ideas?)

Also get Vitamin D levels checked, GP can do this.

@Seasider2017 - no we don't do every little thing for her. For basic things such as taking her medicine, drinking water - we will only remind her if she has missed it. For things we would like for her to get back to doing herself - cooking, making calls to her children... then we do encourage and maybe kick start. If she hasn't bathed in days, then we may really get forceful by nagging her, walking her to the bathroom.

I don't even feel she is overly anxious half the time. She is just very comfortable to say "no". But then if you keep asking and asking, she can do it. Thats the part getting tiring for us. You don't ask you don't get.

The worst of panic attacks anxiety was the build up to her trip to india. Or an upcoming home visit by her CPN. When parachuted into a situation, she cannot dwell and therefore doesn't panic.

You have raised something about her concentration span. She can flick like switch and get a burst of anxiety half way through a convo. She went doctor last week, was relaxed for half of it, then held the arm rests because she wanted to get up. then Doctor got her talking about india again, and she became relaxed again.

She is a little more grumpy and fed up. She really doesn't like any comments talking about her in a positive way, or any compliments. She down plays anything 'good' we think she has done.

My mum is 65.

Yes, she we are big on Vit D in our house, and without supplments I doubt she gets enough.

@Orangesandlemons77 - she has a CPN who visits. My mum doesnt open up. I don't even believe there was a trigger. Just a UTI she had, got dillusional and I feel she never really been the same since. She has improved in the past year. I do think the Mirtazapaine and Venfleaxine helps her. But I think something also holds back her emotions too.
CPN told me she doesn't think the Olanzapine is required. But Doctor has so far not thought the same.

She lives at home with my dad and brother. Me and my 7 month baby are only 15 minutes away. We are her family. In India it was more that she was in the deep end every day. She had her own space and did go lie in bed for a few hours each day, but she knew she had to be present as the only aunt of the groom. Keeping busy is a way she can mask how she is - but its not often she finds herself in that situation.