Xanax & Nighttime Dose?
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Q:  Xanax & Nighttime Dose?

I've been on Prozac for years as I was diagnosed with major depression however in the last year I've been diagnosed bipolar2.  Strong family history of manic depression. Prozac seems to be the only antidepression that lifts my depression. I've tried mood stabilizers and they seem to bring me down too much so I take benzodiazepines.  First I took Ativan and then my doctor wanted me to try Clonazepam as it stays in system longer so not as many ups and downs however that also seems to bring me down causing more depression. He has now prescribed Xanax.  My question is even though I have anxiety I don't have trouble sleeping (sometimes too much), so is it necessary to take the Xanax or any benzo at nightime as well as during the day?

Dear Ms. B' -- 
In my view the first step here is to make sure that the "anxiety" is not some form of bipolar-like symptom that could be being made worse by the antidepressant (sounds like you're still on the Prozac, right?). If that was so, in my experience it would be hard to ever make that go away as long as the antidepressant was still around; or if you could, you'd have to pile on quite a bit of benzodiazepine (Xanax, Ativan, Clonazepam) and it would seem to "stop working". That loss of response could be the development of tolerance to the benzodiazepine, or it could be the continued evolution of unquieted bipolar mixed state that was being pushed along by the antidepressant.  Note, "could be", not "is".  These interpretation has to be considered because it leads to a very different approach; but this interpretation is not necessarily correct. There are two research groups (led by J. Amsterdam and G. Parker) who believe that some versions of bipolar II can be managed on with an antidepressant alone as the "mood stabilizer". 

As you can imagine, if my concern was correct, then you'd have to look for some alternative to the Prozac to address the depression. Fortunately there are mood stabilizers that have antidepressant effects (here is my list of 9 "antidepressants that aren't antidepressants", some of which are also "mood stabilizers" of a sort. Again, not that I'm recommending a wholesale switch in approach; just an additional option to think about. 

Now, as for your question: sounds like you could discuss with your doctor (perhaps already have, by this time?) a trial of using some of the total daily dose at night; versus using it all during the day instead (perhaps spread out through the day, as Xanax doesn't last a whole day for many people, as you probably have discovered).  You see, that was the simple answer to your question. I hope that turns out to be all you need; but in case you need more than that, I hope that the first couple of paragraphs might be of use as well. 

Dr. Phelps

Published October, 2006


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