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1 hour ago, browri said:

So you've gained LESS weight on paroxetine than you did on fluoxetine? You'd probably be a first.

That being said, your current cocktail of paroxetine/clobazam/clozapine is actually littered with interactions. Paroxetine inhibits CYP1A2 and CYP2D6 which will increase levels of clozapine. Additionally, paroxetine itself is metabolized by CYP2D6. So it inhibits not only clozapine's metabolism but its own as well. Furthermore, clobazam is known to inhibit CYP2D6, which would only have a downstream effect of increasing paroxetine levels and therefore clozapine levels even further, and by inhibiting CYP2D6, it would also directly inhibit clozapine as well. So when it comes to drug-drug interactions, trading fluoxetine for paroxetine would be trading apples for apples. Except one of your meds would be stimulating instead of all three being sedating.

That being said, the combination you are on now will interact with the vast majority of any other medication you could possibly add. So a few probing questions:

Were you on clozapine and clobazam first and then added paroxetine? Or how did your current combination transpire? If this is the case, it's possible that the sleepiness was introduced when you added the paroxetine and it dramatically changed the way the other two medications affected you. It's possible that adding the paroxetine meant you needed to actually DECREASE one of the other two meds (either clozapine, clobazam, or both) to compensate for the changes in drug metabolism.

Did you take the risperidone at night? You are correct that paroxetine would make the risperidone persist in your system and increase plasma levels. So perhaps the 0.5mg dose is sufficient and again may allow you to come down on the clozapine which may reduce sedation.

Then perhaps what you need to do is go back and try some of those meds again, specifically the ones you can recall were the MOST tolerable as it seems like none of them were, but there was likely a degree of intolerance for each that only you would be able to determine. So the real question would be, is paroxetine your magic pill or did it just happen to be what you tried after you stabilized yourself with clobazam?

I would second @argh's suggestion and augment the paroxetine with a small dose of bupropion. However, I personally wouldn't recommend starting on the generic 150mg XL (24-hour extended release) because I find that they really aren't great quality. I would recommend starting with 100mg of the SR formulation (12-hour sustained release) in the morning and you can step it up to 100mg twice a day but I think you'll find with the paroxetine on-board that it will inhibit the metabolism of bupropion. Thus, lower doses may be more tolerable and will "go further" than they would for most people who aren't taking medications with impact on metabolism.

If you do find that you're getting tired at the end of the day, then that's when you would move to twice daily dosing with the SR formulation. However, if you wanted to switch to the 24-hour, you could try the 150mg XL at this point or you can switch to Aplenzin which is a different bupropion salt and has a better extended release mechanism in my experience that doesn't make you as jittery. Much smoother release of the drug throughout the day. The 150mg Wellbutrin XL dose would be equivalent to 174mg of Aplenzin.

I actually never gained on Prozac, had very little side effects on that med. 

 

paxil I had side effects, it worked, and my weight fluctuates a bit 

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10 minutes ago, looking for answers said:

I actually never gained on Prozac, had very little side effects on that med. 

 

paxil I had side effects, it worked, and my weight fluctuates a bit 

I actually LOST weight on Prozac.....Paxil made me gain......YMMV, I guess.

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On 5/31/2019 at 12:06 AM, clinic said:

fluvoxamine gives me intense sedation. Plus it increases the blood levels of clozapine which i dont want. fluvoxamine does not gives me energy or fixes fatigue

It's like you didn't read what I said... lol

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3 hours ago, mikl_pls said:

It's like you didn't read what I said... lol

Yea, u said fluvoxamine could help me reduce my clozapine. But i just found out that I'm 100% certain my sedation is caused by my benzo(clobazam). 

I reduced the benzo from 20 to 15mg and I dont have sleepiness today!

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21 hours ago, browri said:

That being said, your current cocktail of paroxetine/clobazam/clozapine is actually littered with interactions. Paroxetine inhibits CYP1A2 and CYP2D6 which will increase levels of clozapine. Additionally, paroxetine itself is metabolized by CYP2D6. So it inhibits not only clozapine's metabolism but its own as well. Furthermore, clobazam is known to inhibit CYP2D6, which would only have a downstream effect of increasing paroxetine levels and therefore clozapine levels even further, and by inhibiting CYP2D6, it would also directly inhibit clozapine as well. So when it comes to drug-drug interactions, trading fluoxetine for paroxetine would be trading apples for apples. Except one of your meds would be stimulating instead of all three being sedating.

oh, atleast all of them are inhibiting each other and not inducing it. That could have been a bigger problem lol

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Just a thought, but my dietitian put me onto daily B complex vitamins. I take it around lunch time, and it helps me get through the day. Helps much more than expected

 

I've never been on clozapine, or benzos though. And YMMV

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Lemme see if I got all this correct.

Thus far, you have said:

  • Provigil and Nuvigil cause psychosis
  • Sertraline > 25 mg causes psychosis
  • Strattera increased anxiety and caused early wakefulness
  • Fluoxetine caused a lot of weight gain and increased blood levels of clozapine (almost anything is going to do this btw)
  • You plan to start risperidone 0.5 mg for cognitive symptoms induced by clobazam
  • All SSRIs (besides paroxetine) cause crying
    • Clobazam made the crying go away
  • Fluvoxamine caused intense sedation (it did for me too), increases blood levels of clozapine, doesn't give energy or remedy fatigue (I can see that)
    • My point I was trying to make was try a low dose of fluvoxamine (baby dose even) to increase clozapine just enough for you to be able to lower the clozapine and have the same therapeutic effect.
    • However, I don't blame you for not wanting to go on fluvoxamine.
  • You are open to the idea of switching benzos (need to be careful which one you chose, as it needs to be efficacious for your myoclonic jerks and history of seizures)
  • You have clozapine-induced anxiety.
    • Does this mean you get anxiety from taking clozapine?
  • Clobazam is for your myoclonic jerks but also anxiety as well.
  • Paroxetine isn't really even good for anxiety, but good for mood (so you have depressive symptoms)
  • Can't take bupropion because of history of seizures.
  • Reduced clobazam to 15 mg and sedation has gone away.

As for the SSRIs, have you tried...

  • Citalopram
  • Escitalopram

Do the dual reuptake inhibitors (SNRIs) cause problems for you?

  • Venlafaxine ER
  • Desvenlafaxine
  • Duloxetine
  • Fetzima (levomilnacipran)
  • Milnacipran

Strattera gave you problems, but is reboxetine available where you live, and have you tried it?

Are TCAs off limits? If not, have you tried desipramine, nortriptyline (high dose), or protriptyline? They tend to be energizing and stimulating. They are more NRI than SRI, especially desipramine.

Regarding the clozapine, I assume you've tried pretty much every antipsychotic... But have you tried:

  • olanzapine (weight gain and sedation would still be an issue, but not as much drug interactions, mechanism of action similar to clozapine)
  • quetiapine/quetiapine ER (same as olanzapine)
  • Saphris (asenapine) (similar to quetiapine except more potent, less weight gain, but risk of QTc prolongation is a possibility)
  • Latuda (lurasidone) (good for cognitive issues and weight neutral, may even lose weight)
  • aripiprazole (high dose)
  • Rexulti (brexpiprazole)
  • Vraylar (cariprazine)
  • loxapine (actually metabolizes into the antidepressant amoxapine which itself also has antipsychotic properties, similar to clozapine but without the seizures, weight gain, and less sedation in the lower doses, acts like an atypical antipsychotic in doses at or less than 25 mg)

Be careful lowering your clobazam dose. If you have a history of seizures and have myoclonic jerks, have you considered something like levetiracetam?

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16 hours ago, mikl_pls said:

Lemme see if I got all this correct.

Thus far, you have said:

  • Provigil and Nuvigil cause psychosis
  • Sertraline > 25 mg causes psychosis
  • Strattera increased anxiety and caused early wakefulness
  • Fluoxetine caused a lot of weight gain and increased blood levels of clozapine (almost anything is going to do this btw)
  • You plan to start risperidone 0.5 mg for cognitive symptoms induced by clobazam
  • All SSRIs (besides paroxetine) cause crying
    • Clobazam made the crying go away
  • Fluvoxamine caused intense sedation (it did for me too), increases blood levels of clozapine, doesn't give energy or remedy fatigue (I can see that)
    • My point I was trying to make was try a low dose of fluvoxamine (baby dose even) to increase clozapine just enough for you to be able to lower the clozapine and have the same therapeutic effect.
    • However, I don't blame you for not wanting to go on fluvoxamine.
  • You are open to the idea of switching benzos (need to be careful which one you chose, as it needs to be efficacious for your myoclonic jerks and history of seizures)
  • You have clozapine-induced anxiety.
    • Does this mean you get anxiety from taking clozapine?
  • Clobazam is for your myoclonic jerks but also anxiety as well.
  • Paroxetine isn't really even good for anxiety, but good for mood (so you have depressive symptoms)
  • Can't take bupropion because of history of seizures.
  • Reduced clobazam to 15 mg and sedation has gone away.

As for the SSRIs, have you tried...

  • Citalopram
  • Escitalopram

Do the dual reuptake inhibitors (SNRIs) cause problems for you?

  • Venlafaxine ER
  • Desvenlafaxine
  • Duloxetine
  • Fetzima (levomilnacipran)
  • Milnacipran

Strattera gave you problems, but is reboxetine available where you live, and have you tried it?

Are TCAs off limits? If not, have you tried desipramine, nortriptyline (high dose), or protriptyline? They tend to be energizing and stimulating. They are more NRI than SRI, especially desipramine.

Regarding the clozapine, I assume you've tried pretty much every antipsychotic... But have you tried:

  • olanzapine (weight gain and sedation would still be an issue, but not as much drug interactions, mechanism of action similar to clozapine)
  • quetiapine/quetiapine ER (same as olanzapine)
  • Saphris (asenapine) (similar to quetiapine except more potent, less weight gain, but risk of QTc prolongation is a possibility)
  • Latuda (lurasidone) (good for cognitive issues and weight neutral, may even lose weight)
  • aripiprazole (high dose)
  • Rexulti (brexpiprazole)
  • Vraylar (cariprazine)
  • loxapine (actually metabolizes into the antidepressant amoxapine which itself also has antipsychotic properties, similar to clozapine but without the seizures, weight gain, and less sedation in the lower doses, acts like an atypical antipsychotic in doses at or less than 25 mg)

Be careful lowering your clobazam dose. If you have a history of seizures and have myoclonic jerks, have you considered something like levetiracetam?

I might try prozac 20mg as last option, so far I have decided if things dont work out I might change my benzo and not the antipsychotic. To be honest, it takes months to find the right med and the right dose. I'm not going change what is already working for me such as clozapine and paroxetine. If everything fails I can try olanzapine and maybe decrease clozapine to 100mg from 200 ? or maybe stop it altogether. Don't know if pdoc will agree with me or not. The main problem is my benzo clobazam which is causing the sedation. Right now its been 2 days since I reduced it to 15mg from 20mg, and I'm feeling no sleepiness/tiredness.

The problem is I'm worried I might cry after taking 1st dose of risperidone 0.5mg with clobazam 15mg

Here's what happened before

Earlier when I was on same 3 cocktail meds as on my sig except I was on tiny clobazam dose 5mg(5mg works for myoclonic jerks). When I took risperidone 0.5mg with clobazam 5mg, I started crying so loud. But after some weeks when I took risperidone 0.5 + clobazam 20mg instead of 5mg, I did not cried at all and there was no anxiety. So clobazam 5mg makes me cry when i take it with risperidone 0.5 but clobazam 20mg does not. I was able to tolerate risperidone this time cuz of increased clobazam. I used to cry on 1st dose of all SSRI/SNRI/beta blockers but after taking them along with clobazam, the crying went away.

Yea after lowering my clobazam I had slight feeling of crying but I'm sure this will go away.

Regarding meds
When I took Escitalopram along with paroxetine, I had speech problem like words did not come out correctly. I can try low dose strattera again, I only had anxiety on it. But does strattera fix sleepiness ? This is all hypothetical. I will only take wakefulness meds only if risperidone did not work on 15mg clobazam and i might have to increase it again back to 20mg, if it does work on clobazam 15mg then i dont need any med to reduce sleepiness. Yea, I dont wanna try TCAs. After everything fails, I will take olanzapine. I have changed my lifestyle and lost like 15kg on clozapine so far. I'm no longer waking up middle of the night to eat food.

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10 hours ago, clinic said:

I might try prozac 20mg as last option, so far I have decided if things dont work out I might change my benzo and not the antipsychotic. To be honest, it takes months to find the right med and the right dose. I'm not going change what is already working for me such as clozapine and paroxetine. If everything fails I can try olanzapine and maybe decrease clozapine to 100mg from 200 ? or maybe stop it altogether. Don't know if pdoc will agree with me or not. The main problem is my benzo clobazam which is causing the sedation. Right now its been 2 days since I reduced it to 15mg from 20mg, and I'm feeling no sleepiness/tiredness.

The problem is I'm worried I might cry after taking 1st dose of risperidone 0.5mg with clobazam 15mg

Here's what happened before

Earlier when I was on same 3 cocktail meds as on my sig except I was on tiny clobazam dose 5mg(5mg works for myoclonic jerks). When I took risperidone 0.5mg with clobazam 5mg, I started crying so loud. But after some weeks when I took risperidone 0.5 + clobazam 20mg instead of 5mg, I did not cried at all and there was no anxiety. So clobazam 5mg makes me cry when i take it with risperidone 0.5 but clobazam 20mg does not. I was able to tolerate risperidone this time cuz of increased clobazam. I used to cry on 1st dose of all SSRI/SNRI/beta blockers but after taking them along with clobazam, the crying went away.

Yea after lowering my clobazam I had slight feeling of crying but I'm sure this will go away.

Regarding meds
When I took Escitalopram along with paroxetine, I had speech problem like words did not come out correctly. I can try low dose strattera again, I only had anxiety on it. But does strattera fix sleepiness ? This is all hypothetical. I will only take wakefulness meds only if risperidone did not work on 15mg clobazam and i might have to increase it again back to 20mg, if it does work on clobazam 15mg then i dont need any med to reduce sleepiness. Yea, I dont wanna try TCAs. After everything fails, I will take olanzapine. I have changed my lifestyle and lost like 15kg on clozapine so far. I'm no longer waking up middle of the night to eat food.

 

7 hours ago, clinic said:

Have you considered adding a second AAP? Like aripiprazole or ziprasidone? Lurasidone would also be a good option to consider.

Did you try pindolol when you were taking beta-blockers? It is a low intrinsic activity partial agonist or functional antagonist at the 5-HT1A receptors, which disinhibits serotonin release. Buspirone does a similar thing but via partial agonism at moderately high intrinsic activity, so it initially decreases serotonin but after all the presynaptic 5-HT1A receptors become downregulated, the serotonin disinhibition and subsequent release occurs. (Although clozapine does this too.) It also stimulates postsynaptic 5-HT1A receptors which causes downstream dopamine release in certain parts of the brain. Low doses antagonize the presynaptic dopamine autoreceptors and therefore cause dopamine release, but high doses will also antagonist postsynaptic dopamine receptors and therefore have somewhat of an antipsychotic action.

Gabapentin seems to be an option, but it's sedating (or can be). Same with pregabalin.

What about mirtazapine or mianserin (not sure where you live and what's available where you live)? Low dose sulpiride or amisulpride? Low dose zuclopenthixol?

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The sedation from gabapentin does wear off as your body gets used to it. Absolutely fantastic for my anxiety and depression. Seems mr b, in that pdf had good luck with it.

i see that you dont have a mood stabilizer in your cocktail. That a possibility? Most of them are anticonvulsants. 

carbamazepine, oxcarbazepine, valproate? 

Non sedating? Lamotrigine. Though in all fairness it does sedate me quite a bit at my dose..which it shouldn’t...or maybe that is the whole mood stabilization kicking in.

all of those, to a greater or lesser extent help with anxiety. The former are anti manic in case your case with some studies indicating efficacy for psychosis. Might help you lower your clozapine.

https://www.ncbi.nlm.nih.gov/pubmed/2283596

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2 hours ago, argh said:

i see that you dont have a mood stabilizer in your cocktail. That a possibility? Most of them are anticonvulsants. 

carbamazepine, oxcarbazepine, valproate? 

Non sedating? Lamotrigine.

I completely missed that! Nice catch!

I can vouch for oxcarbazepine and lamotrigine. I took lamotrigine and it worked fairly well, but it caused horrible acne all over my back and shoulders; however, lamotrigine is somewhat stimulating, especially at low doses, somewhat at higher doses (for me anyway, YMMV). Oxcarbazepine strangely enough helps with my depression at 1200 mg, but it also helps with my anxiety. It's neither stimulating nor sedating for me.

Carbamazepine caused me to hear everything about 1 semitone flat, and as a musician, I couldn't stand it. I was only on 200 mg at bedtime, so my pdoc told me to stop it.

VPA will definitely calm you down, but it will definitely be somewhat sedating and possibly problematic for sedation for some people. When I took just 500 mg ER, it made me a zombie. I lost track of time all the time, and 3 weeks went by and I had no clue what I had done during that time. It was for an acute manic episode, and as soon as I went off it, I became manic again, so we did something else (can't remember at the time...) Oh, and it will make you gain weight.

Levetiracetam is another anticonvulsant they sometimes use to help mania and anxiety even, but it has the possibility of inducing the "Keppra Rage" or inducing suicidality and depression. I had the latter when I reached 1000 mg/day. It's weight neutral, and neither sedating nor stimulating.

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Here's what i can add

1. Add risperidone 0.5(for cognitive symptoms)
2. Add prozac 20mg(for energy)
3. Add aripiprazole 2mg(for energy as well but causes worsening paranoia, but can try again)
4. Strattera(Atomoxetine)(for energy)

Those anticonvulsants, I had problems on all of them. I want to be brief, cant explain more about it. The only anticonvulsant which worked best for me is my benzo clobazam. I can't take beta blockers now with clozapine due to postural hypotension

Edited by clinic

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is the point of another AAP to provide coverage while you reduce the clozapine?

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15 minutes ago, argh said:

is the point of another AAP to provide coverage while you reduce the clozapine?

No, they r just add-ons, i wont decrease clozapine

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15 hours ago, mikl_pls said:

I can vouch for oxcarbazepine and lamotrigine. I took lamotrigine and it worked fairly well, but it caused horrible acne all over my back and shoulders; however, lamotrigine is somewhat stimulating, especially at low doses, somewhat at higher doses (for me anyway, YMMV). Oxcarbazepine strangely enough helps with my depression at 1200 mg, but it also helps with my anxiety. It's neither stimulating nor sedating for me.

I can vouch for both as well with similar experiences. Lamotrigine is stimulating in the beginning and can be kind of rocky titrating up, but once you get past 100-150mg, it gets much better. As for oxcarbazepine, I can also vouch for it being "soothing". When I was on the immediate release, I would get the "feel good buzz" a bit an hour or two after taking it. Sometimes sooner. It's calming and in that regard, because you're calm, you are oftentimes less depressed as well. YMMV of course. Oxcarbazepine and its parent carbamazepine (more below) both appear to be modest serotonin releasing agents, more so for the parent.

15 hours ago, mikl_pls said:

Carbamazepine caused me to hear everything about 1 semitone flat, and as a musician, I couldn't stand it. I was only on 200 mg at bedtime, so my pdoc told me to stop it.

Had the same experience and it was a TOTAL show stopper. If you consider yourself to be musical in any way or if you have really good pitch and like that about yourself, you probably won't be happy with carbamazepine.

15 hours ago, mikl_pls said:

VPA will definitely calm you down, but it will definitely be somewhat sedating and possibly problematic for sedation for some people. When I took just 500 mg ER, it made me a zombie. I lost track of time all the time, and 3 weeks went by and I had no clue what I had done during that time. It was for an acute manic episode, and as soon as I went off it, I became manic again, so we did something else (can't remember at the time...) Oh, and it will make you gain weight.

I can second some of this. VPA (valproate / valproic acid or Depakote's mixed formulation, divalproex) can be quite calming. At doses too high it can be depressogenic (actually causes depression). It isn't good for depression directly obviously, but if a lot of a person's depression stems from roots in anxiety, low doses of Depakote can be calming enough to "smooth" things over. I'm currently only taking 500mg of the ER as a maintenance dose, and I'm 6 foot and ~190 pounds. It doesn't yield what is considered a "therapeutic" blood level (50-100 mcg/mL) but as a maintenance dose it helps in combination with Rexulti to keep things under control so I don't have another mixed or hypomanic episode.

Depakote can cause weight gain for many. YMMV but Depakote almost invariably causes at least a LITTLE bit of weight gain but more moderate weight gain than anything. I tend to fluctuate in weight between 180 lbs and 200-210 lbs depending on my mood. That being said, I'm also taking Depakote with Rexulti, which is a gainer, and Trintellix has been shown to cause some weight gain in post-marketing reports, and the weight gain from Trintellix and Rexulti compounds each other due to the effect at 5HT2C receptors. My weight floats across about a 20 lb range.

Depakote works by inhibiting the breakdown of GABA into glutamate and induces the conversion of glutamate back into GABA thus dampening the glutamate system and increasing the brain's GABA supply. It also may induce monoamine oxidase A to recycle excess serotonin and inhibit the synthesis of new catecholamines like norepinephrine and dopamine, all of which has the net effect of calming the brain quite a bit. Because there's SO much going on with VPA, if you aren't in a crisis situation, it's best to start at 250mg for 3-5 days, then go to 500mg for a while and see how it feels after long term use. For me, I need Depakote and Rexulti to keep things calm, but I could never find a low dose combo of the two that controlled my bipolar disorder but didn't make me feel depressed. So we added Trintellix, which actually increases glutamate signaling to fight back against the Depakote a bit. So I end up with a higher GABA supply but less glutamate "dampening" than if I took Depakote alone. The net result is a pretty solid balance.

To be clear, Depakote is not for everyone. For example, it can have androgenic (pro-testosterone) effects. For this reason, it sometimes just isn't a good option for some women. As you can see, @mikl_pls doesn't tolerate it very well. It seems to work for his mania from what he's said, but at what cost? By contrast, I absolutely CANNOT tolerate lithium. Don't get me wrong. It works. It stabilizes me. It reduces my suicidal thinking and eases my depression. But the side effects are totally intolerable to me. For others, lithium is a miracle drug and they tolerate it with no problem.

15 hours ago, mikl_pls said:

Levetiracetam is another anticonvulsant they sometimes use to help mania and anxiety even, but it has the possibility of inducing the "Keppra Rage" or inducing suicidality and depression. I had the latter when I reached 1000 mg/day. It's weight neutral, and neither sedating nor stimulating.

Personally don't have any experience with levetiracetam, but it should be considered like third or fourth line option (used after 2-3 options have failed) as a mood stabilizer after VPA/lithium, lamotrigine, carbamazepine, and oxcarbazepine (in order of preference)

8 hours ago, clinic said:

Here's what i can add

1. Add risperidone 0.5(for cognitive symptoms)

If you wanted to improve cognition and daytime energy while still improving sleep, I would personally HIGHLY recommend vortioxetine (Trintellix). It improves my cognition so well that I can actually take a lower dose of my stimulant than I would normally need without the vortioxetine. The paroxetine would be traded for this, but it could kill two birds with one stone. That being said, it sounds like you've already addressed the sedation by lowering the clobazam to 15mg. However, if you found that you needed to go back up to 20mg on the clobazam, maybe swapping out the paroxetine for vortioxetine is something you could look into.

8 hours ago, clinic said:

Those anticonvulsants, I had problems on all of them. I want to be brief, cant explain more about it. The only anticonvulsant which worked best for me is my benzo clobazam. I can't take beta blockers now with clozapine due to postural hypotension

I imagine the reason clobazam is the only benzo that works for you is because it focuses on the alpha-2 subunit of the GABA-A receptor instead of the alpha-1 subunit like all the other ones related to diazepam.

7 hours ago, clinic said:

No, they r just add-ons, i wont decrease clozapine

Why not decrease clozapine? Of all the AAPs (atypical antipsychotics) it actually carries the highest risk of all of them being fairly diabetogenic (causese type 2 diabetes) like olanzapine (Zyprexa) and having a much higher risk of neutropenia (low neutrophil count) than any other AAP.

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9 hours ago, clinic said:

Here's what i can add

1. Add risperidone 0.5(for cognitive symptoms)
2. Add prozac 20mg(for energy)
3. Add aripiprazole 2mg(for energy as well but causes worsening paranoia, but can try again)
4. Strattera(Atomoxetine)(for energy)

Those anticonvulsants, I had problems on all of them. I want to be brief, cant explain more about it. The only anticonvulsant which worked best for me is my benzo clobazam. I can't take beta blockers now with clozapine due to postural hypotension

 

8 hours ago, clinic said:

No, they r just add-ons, i wont decrease clozapine

I can't help you any further. There is a trend for you asking for help and shooting down almost every response or idea.

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23 minutes ago, browri said:

If you wanted to improve cognition and daytime energy while still improving sleep, I would personally HIGHLY recommend vortioxetine (Trintellix). It improves my cognition so well that I can actually take a lower dose of my stimulant than I would normally need without the vortioxetine. The paroxetine would be traded for this, but it could kill two birds with one stone. That being said, it sounds like you've already addressed the sedation by lowering the clobazam to 15mg. However, if you found that you needed to go back up to 20mg on the clobazam, maybe swapping out the paroxetine for vortioxetine is something you could look into.

Vortioxetine is not available in my country.

You see increasing dopmaine even a little bit is not a choice for me. See what happened with sertraline. Sertraline which is a SSRI increases dopamine little bit, I got highly paranoid on 50mg sertraline. I can't even drink coffee, i get so paranoid. I'm extremely sensitive to increased dopamine.

If I increase clobazam again to 20mg then I can only risk increasing norepinephrine(NRIs) instead of dopamine(DRIs) for wakefulness.  I can try strattera(atomoxetine) for that. If you know better NRI, let me know.

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5 minutes ago, mikl_pls said:

 

I can't help you any further. There is a trend for you asking for help and shooting down almost every response or idea.

I'm not shooting down your idea. The meds u suggested have not worked for me. I've already tried them

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I will wait few days. Its not even been a week on reduced clobazam 15mg. Once 1 week is complete, I will start risperidone to see how it goes. If I start crying, I'll have to increase my benzo 

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