I've entered the daytime treatment at the University Medical Centre of Groningen. I was very resistant at first, but now I'm getting the hang of it. The therapists are actually pretty good. The co-patients are nice. I like being part of a group; hanging out with people and having good conversations.

I've had an appointment with a p-doc and a doc-assistant. The p-doc was the guy in charge of the Anxiety & Compulsion department. He was a very friendly man. The doc-assistant was a sharp eyed woman whose look became more and more stern as I revealed the myriads of meds I've been trying, mostly on my lonely own.

I chose for complete honesty. It was a decision I made spontaneously in the beginning of our conversation, though several events had paved the way for it.

Indeed, their stance towards medications is that they prefer, ideally, to have a patient try cognitive behavioral therapy with exposure therapy first - without meds, and see how far he/she gets, and only then, if medication is still necessary, look at pharmacotherapy. The idea is that meds that help with anxiety undermine what exposure is all about: dealing with anxiety upfront, and learning to walk without crutches, so to speak. Nevertheless, they don't urge you to quit any medication right away; they are aware that quitting meds can cause withdrawal syndromes and that this should happen when someone is ready for it. So, in practice, they have people continue some of their meds, while urging them to taper off others.

Another stance that they have towards meds is that they think any med prescription should be 'evidence based', which means that they don't support off-label prescriptions. They only support prescribing a drug for the conditions for which it has been approved. They think this is the only truly scientific way of going about it.

I strongly disagree! The indications for which a med gets approved are often not based on sound science, but on the guesses of the pharmaceutical company that markets the med. A pharmaceutical company will try to market a drug for a certain condition and might not be interested to fund research after other applications. Moreover, at the time a drug gets approved, there is often very little known about its precise working mechanisms. In time, the knowledge about a drugs specific modes of action will grow, and these new discoveries may point to other applications than that for which the drug had first been approved. Then there are the many drugs who have run out of patent, and don't have million dollar companies behind them to further explore their possibilities.

The way I see it, only prescribing meds according to protocols means not looking at what a drug actually does, but only looking at what it has been approved for. This is not true science - this is submission to statistics! Submitting sound thinking to the power of the number - a power that has many stronger powers behind it and is influenced by these in very subjective ways.

I think one of the reasons why Dr. Stephen Stahl is such a brilliant psychiatrist is precisely because he doesn't just look at the numbers, but looks at what a drug actually does in the brain and in the body.

An example of the tension between true science and the subjective game of drug approvals is the fact that fluvoxamine, i.e. Luvox, has only been approved for OCD in the United States, but not for depression. Luvox though is an SSRI like any other, and can therefore be an effective antidepressant as well as an effective treatment for OCD. In most countries, Luvox is approved for both conditions. Would this mean that Luvox would help Dutch patients with depression, but can help Americans only with OCD? That is pure nonsense, of course.

Luvox can serve as a further illustration of my point. Years after Luvox had been approved for depression and(/or..) OCD, it has been discovered that the drug is a potent sigma-1 agonist. Sigma-1 receptors play a role in depression and anxiety, but also in delusions. One study explored the latter possibility and gave 300mg of Luvox to a group of patients with schizophrenia for an extended period of time. This high dose of Luvox appeared to be very effective for schizophrenia. But it's only one study; the drug is off patent, so there is no money to confirm these results with further research - Luvox' possible use as an antipsychotic med will probably never be exploited. And why not? Because people - meaning healthcare professionals! - don't look at what a drug actually does, but only look at the label.

The psychiatrist of the treatment centre wasn't too happy about most of the meds I take. The Zoloft (sertraline) was alright, since it has been approved for OCD.. I could continue taking it until I was ready to taper it down. The Buspar made them frown, since it has only been approved for General Anxiety Disorder, not for OCD.. The fact that it helps me is apparently not relevant! The Neurontin (gabapentine) puzzled them evn more. Is it the right med for the type of pain I have? The fact that even in small amounts it helps me tremendously with anxiety, is of no importance, since it hasn't been approved for anxiety disorders! Also, my TCA's didn't make them very merry. Later, when I thought about it, I figured I could have them support my amitriptyline (Elavil), since it has officially been approved for chronic pain.. Of course, amitriptyline would also help me with depression and anxiety. But that would be a counter-argument, since they don't want my meds to make my life too comfortable!

I hope you can see how debatable and far removed from real life their position is.

For now, they leave the pharmacotherapeutical responsiblity with my f-doc, with whom they want to discuss my medical regimen.

As for me, I know I am obsessed with meds, and I know my way of experimenting with meds is rather capricious. Still, I have great difficulty to submit to a professional view that is not mine and that I am very critical of.

I am still interested in 5HT2A/C-antagonism, of which I have talked here (and elsewhere) before. Servier's new drug agomelatine (Valdoxan) is a 5HT2C-antagonist, but only a rather weak one, it seems. Prozac is a pretty potent 5HT2C-antagonist, and I'm thinking of returning to low dose Prozac for this reason. Cyproheptadine, an old antihistaminergic drug, has my interest because it's a potent 5HT2A-antagonist and also a moderately strong 5HT2C-antagonist. Unlike amitriptyline, which is a much stronger antihistaminergic than a 5HT2A/C-antagonist, cyproheptadine's 5HT2A-antagonism is about as strong as its antihistaminergic properties.

I'm still taking amitriptyline (Elavil), and have upped my dose to 25mg, and more recently (yesterday) to 37.5mg. Amitriptyline offers both 5HT2A and -C antagonism (or -C partial agonism). It's too bad that it's such a strong antihistaminergic. I have noticed though that when I go up slowly, I quickly develop tolerance for the antihistaminergic sedation.

The Neurontin (gabapentin), as stated above, helps very well with anxiety. I have noticed no pain relief from it yet, though, and sometimes I even suspect it might paradoxically make my pain worse. I think I need to go to a higher dose to have a better idea of what it's doing.

I have now tried Valium (diazepam) three times, and boy, I love it. It's much less sedating than Ativan (lorazepam); it leaves my cognitive abilities mostly intact; it doesn't even seem to impair my memory (hardly any retrograde amnesia); and it gives me an antidepressant and anxiety-defeating boost. 'Mother's little helper' - indeed. Daddy likes it too.

But well, at the treatment centre - you may have guessed it - they're not too fond of benzo's.. No way they're gonna prescribe that, unless you're hooked already, in which case they're gonna make a plan for you to taper off. Hm, I've been honest, so I told them I have no physical dependence on benzo's..

Perhaps taking Valium daily for a prolonged period of time isn't a good idea anyway. Some people on some forums swear that long-term use of Valium will eventually make you more depressed. Anybody any comment on that? I should ask on the benzo board, I guess..

As for modafinil (Provigil), selegiline, amisulpride, piribedil.. I have only a couple of pills left. And I have no income at the moment. I'm parasitizing on my wife. Plus at the treatment centre, they want me to leave those drugs. Hm.

Well, that's all for now, folks. Feel free to ask any questions and give any feedback. Be gentle..