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Ask Dr Ivan 5

In the fifth of his regular column, Dr Ivan Goldberg, MD, Director, N.Y. Psychopharmacologic Institute, New York, NY, answers a few of the many questions that arrive in our mailbox. We are sorry, but Dr Goldberg cannot enter into individual correspondence.

This month:


I know that clonidine has been used for the treatment of PTSD, has anyone used it to treat patients with generalized anxiety?

In 1975 Bjorkqvist described the use of clonidine to reduce the anxiety and tremors that accompanied alcohol withdrawal. Since then, there have been about 75 reports of it being used for the treatment of patients with generalized anxiety or panic disorder.

Ref: Bjorkqvist, SE Clonidine in alcohol withdrawal. , Acta Psychiatrica Scandinavica 1975,52,256-263.


I am a 30 yr old female recently diagnosed with panic disorder. I was given Xanax immediately about 4 months ago. I am currently seeing a psychiatrist and we are using the Cognitive-Behavioral approach. She put me on Zoloft 4 weeks ago and since then I have been Panic free and very low anxiety level if any at all. I have began to decrease the Xanax-starting at bed time. The problem is since I began taking Zoloft I have been sleeping less and waking up often throughout the night. I take Zoloft at bed time. Should I consider taking it in the morning and if so I am worried about side effects that I may be unaware of because I take it at night and I want to continue to function at a high rate while at work. I see my doc weekly and I will discuss this with her. I just wanted your opinion. I will not change any meds or the times I take my meds until I discuss it with her.

Some people find that if they take Zoloft in the morning, they have less sleep disturbance than when it is taken at bed time. Many people have as much sleep disturbance when it is taken in the morning, as Zoloft slowly leaves the blood after having been taken. Zoloft takes few days to leave the body even after it has been totally discontinued.


I was wondering if you could tell me if there have been any studies looking at the possibility that people on SSRIs build up a tolerance. For example, if someone were on Zoloft, is it possible that their body would increase its uptake of 5-HT so as to limit the effectiveness of the Zoloft. The reason I ask the above is because of the fact that that the effectiveness of most other drugs seem to decrease (at some point) as the body down or up-regulates the action of the drug. Could SSRIs just take a longer period of time than say Cocaine with (DA)?

While the body does develop tolerance to many drugs of abuse, it does not necessarily do that when dealing with prescribed drugs affecting the central nervous system. There are many people who have taken tricyclic antidepressants for decades without any need to increase the dose and without any fall-off in efficacy. Some people have taken SSRIs for nearly ten years with continuing good effects.

On the other hand, there have been a small number of people who do report that the antidepressant effects of an antidepressant disappear after some time. Such people will nearly always do well if switched to an antidepressant that belongs to another class of drugs. If the second drug stops working, a switch back to the first will usually be followed by a good response.


Some patients treated with clozapine (Clozaril) show persistent decrease in their platelet count below norm. Other hematologic indices remain normal or bear normal.

How does one evaluate and handle the situation?

While hematologic side effects are a problem for about 1% of people taking clozapine, thrombocytopenia, a reduction in the number of platelets is seldom a problem. Since the introduction of clozapine, just a handful of instances of thrombocytopenia leading to bleeding have been reported. Platelet counts prior to the initiation of clozapine therapy and at intervals thereafter will allow one to track the effects of clozapine on platelets. Discontinuation would be indicated if the patient develops abnormal bleeding or a platelet count that is persistently below 90,000.

Ref: Durst R, Dorevitch A, Fraenkel Y Platelet dysfunction associated with clozapine Therapy. Southern Medical Journal 1993, 86, 1170-1172.


My husband (age 42) is taking recently prescribed Zoloft for a depressive disorder. He has been on this medication for about two months now. He is also using marijuana on an almost daily basis (I am certain he does not tell his psychologist and psychiatrist that he uses marijuana presently, although I do feel that he has told them he has used it extensively in the past). What are or what can be the interactions of these two mind-altering drugs? I feel terribly worried about this.

There are no studies that have looked at the impact of smoking marijuana upon the antidepressant effects of sertraline (Zoloft) or any of the other SSRIs.. It is well known to those who treat many depressed people that one of the commonest reasons for non-response to antidepressant therapy is covert drug abuse.


What is the newest treatment for schizophrenia?

The most important recent development in the treatment of people with schizophrenia is the realization that to treat such people is much more complicated than simply prescribing antipsychotic medications. Schizo- phrenia is a chronic medical illness that impacts on every aspect of living. Medication plus psychosocial therapies must be combined if individuals with schizophrenia are to make the maximum therapeutic gains.

The modern treatment of people with schizophrenia tries to make maximum use of treating the patient in a safe structured or semistructured setting outside of a hospital. While hospitalization is still often required, the psychosocial benefits of community living, and the accom- panying support network, are impressive. Psychotherapeutic and psycho- educational techniques that emphasize behavioral modeling, social skills training, vocational rehabilitation, family therapy, stress management, and crisis intervention have prevented hospitalizations.

When it comes to recent psychopharmacologic advances, the recent development of atypical antipsychotic medications such as clozapine and risperidone have allowed patients to take medications that are both highly effective and free from some of the side effects of the older antipsychotics.

Ref: Kane JM McGlashan TH Treatment of schizophrenia. The Lancet 1995, 346-825.

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