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Suggest Treatment For Depression And Anxiety

Posted on Wed, 19 Feb 2014

Question: Hello Dr XXXXXXX I have been suffering from depression and anxiety for the last 1 year and 7 months. Now I'm taking bupropion 150mg in the morning for 2 months, citalopram 20mg in the morning for 2 months and lorazepan 3 mg 2mg in thee morning and 1mg at 1pm. I don't want to take this medication anymore because the are not doing anything to me only side effects. Also, I took a gen test call Genecept TM Assay report please read and tell what medication base on the report I should take. Thank you, XXXX

Answered by Dr. Preeti Parakh (18 hours later)

Brief Answer: Explained below. Detailed Answer: Hi XXXXXXX Welcome to Healthcare Magic! You mention that you have been on medication for last two months and are not satisfied with the response. You also mentioned having side effects. I have gone through the report of your gene test. According to this report, you are likely to have slow or poor response with SSRI group of medicines and are also likely to have adverse effects with both SSRIs and atypical anti-psychotics. Since your diagnosis is of anxiety and depression, we need not be concerned with anti-psychotics. You are currently on one SSRI citalopram and a second antidepressant bupropion which is not a SSRI. Lorazepam is a benzodiazepine and controls anxiety. The doses of both citalopram and bupropion are low and can be hiked up. However, you have expressed a desire to try a new medication. In my opinion, it should first be assessed which medicine is causing you side effects. I cannot comment on it as you have not specifically mentioned the side effects. But going by your gene test report, bupropion should suit you better than citalopram. These genetic tests have a limitation that they can give information about only those genes that are known. For example, you may have adverse effects from bupropion or any other medicine as well but the test will not be able to tell you so if the specific gene mediating it is not known. That is why, no one can predict that a particular medicine will suit you or not. I feel that once it can be identified which of the two antidepressants is harming you most, the offending agent should be tapered off and the dose of the other one should be hiked. Whether it is working for you or not should be decided only after a few weeks as all antidepressants take a few weeks to show their response. If you are absolutely not willing to continue with both these, then there are some other options like Venlafaxine, Duloxetine and Milnacipran which are SNRIs as well as Mirtazapine and Agomelatine which have completely different mechanisms of action. I personally prefer Venlafaxine for its excellent response but it has some adverse effects similar to that of citalopram. I hope this clears up things for you to some extent. Please feel free to ask if you need any clarifications. Best wishes. Dr Preeti Parakh MD Psychiatry

Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar

Follow up: Dr. Preeti Parakh (1 hour later)

the side effects is that I have crying spell everyday, I feel weak, sexual side effects. one of the symptom of my depression is that I feel an elephant sitting in my chest. The report shows proceed within caution with ssri so I have to stop citalopram right?. I have 3 days that I stop Bupropion. I have tried remeron, vivrid, venlaxifine(Suicidal ideation) , paxil, pristiq, and others ssri. What medication do you refer for crying spells? What do you think about the medication mood stabilizer for depression/anxiety?

Answered by Dr. Preeti Parakh (19 minutes later)

Brief Answer: As below. Detailed Answer: Hi XXXXXXX The crying spells are not side effects but symptoms of depression itself, and can be expected to improve when depression improves. Weakness and the feeling of heaviness is also a symptom of depression. Sexual side effects are common with citalopram and bupropion helps to reduce to them. That is why I feel that you should taper off only citalopram and hike up bupropion to 300 mg per day. Bupropion should be continued for long, ideally for at least a year. Mood stabilizers like lithium and valproate are usually used in bipolar disorder. In people with only depressive disorder, lithium is sometimes used to augment the action of antidepressant but the main medicine is still the antidepressant. That is why, you should first ensure that you are on an adequate dose of an antidepressant. So first the dose of bupropion should be hiked up and then it should be assessed whether you need any augmentation or not. I expect you to show significant improvement within four to six weeks after hiking the dose of bupropion. Citalopram should be tapered off after you become stable on the higher dose of bupropion. Best wishes. Dr Preeti Parakh MD Psychiatry

Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar

Follow up: Dr. Preeti Parakh (36 minutes later)

Thank you for your response. What do you think about brand wellbutrin xl and generic bupropion xl do you think the work the same? I heard very bad comments from the generic. Thank you, XXXX

Answered by Dr. Preeti Parakh (9 minutes later)

Brief Answer: I do not feel that generics do not work. Detailed Answer: Hi XXXXXXX I do not feel there is any major difference between the performance of Wellbutrin and generic bupropion. Though I agree that you will see many comments on chat forums saying that generic versions do not work. I feel that you should try the generic version and decide for yourself. Generic versions are used all over the world by millions of people and found effective. You should give it a chance. Best wishes. Dr Preeti Parakh MD Psychiatry

Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar

Follow up: Dr. Preeti Parakh (12 minutes later)

Thank you Dr. XXXXXXX Have you heard about a generic brand that works well? THank you, XXXX

Answered by Dr. Preeti Parakh (10 hours later)

Brief Answer: As below. Detailed Answer: Hi XXXXXXX I have heard good reports about the generic bupropion xl made by Watson pharma, Anchen pharma and Sun pharma. Though, what suits one person may not suit another. The problem with generics is not the content of the pill but the drug delivery system that delivers the drug into the body at a steady rate preventing major fluctuations and ensuring a steady level of the drug in the blood. SO if the XL generics do not work, then you can try the SR generics that need to be taken twice a day. That is, 300 mg XL is equivalent to 150 mg SR twice a day. Best wishes. Dr Preeti Parakh MD Psychiatry

Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar

Follow up: Dr. Preeti Parakh (14 hours later)

Thank your for your response. I read that the crying spell is not a symptom of the depression. I don't care if it is or not how I can cope with the crying? Do you think wellbutrin xl will help? Thank you, XXXX

Answered by Dr. Preeti Parakh (2 hours later)

Brief Answer: Explained below. Detailed Answer: Hi, You need to assess what makes you cry. Most likely it is some negative thought that makes you feel low and then burst into tears which are difficult to control. This is what happens in crying spells due to depression. You can control them by countering the negative thought with positive ones. For example, if your boss scolds you for something and you find yourself tearful, identify the thought that came into your mind. It probably would be something like "I am not good for anything. I cannot do anything right." Try replacing it with "It is ok. I may have made a mistake today but I can do so many things well. This will reduce the sadness and prevent tears. What I have explained to you is the basis of cognitive behavior therapy used to treat depression. Crying spells not due to depression are seen in brain disease when certain areas of the brain are damaged due to stroke or other pathology. They are not accompanied with sadness and negative thoughts. Medicines cannot cause crying spells as side effects but they can cause depression as side effects which can then cause crying spells. If possible please let me know where you read about crying spells not being a symptoms of depression so that I can read it myself. Any medicine that can control your depression will help with the crying spells. So I expect Wellbutrin XL will indeed make a difference. Best wishes. Dr Preeti Parakh MD Psychiatry

Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar

Follow up: Dr. Preeti Parakh (16 hours later)

Thank you Dr XXXXXXX I feel in my chest and throat tight during the day everyday at night is when become weak. The sensation in my chest make me feel very weak and that makes me cry I try to see which thought create the crying spell but is an emotion that come from my stomach to my throat that make me feel to cry for no apparent reason. Have you have this type of situation before? What do you think about hypnotherapy for depression and anxiety? Thank you for all your help! XXXX

Answered by Dr. Preeti Parakh (50 minutes later)

Brief Answer: Explained below. Detailed Answer: Hi XXXXXXX The tightness in chest and throat that you have described appear to be due to anxiety. Try shifting your lorazepam from 2 mg in morning and 1 mg at 1 pm to 1 mg three times a day for an equivalent coverage all through the day. I expect that will relieve the abnormal sensation you feel at night. Since lorazepam is short acting, the afternoon dose is no longer working by the time its night. Probably that's why you feel worse at night and are susceptible to tears. From what I have read about hypnotherapy, my idea is that it helps in the short term but is unable to provide lasting benefits. There is something else that may help you. Please try practicing relaxation exercises like progressive muscular relaxation or other similar ones. Detailed instructions are freely available online. I am including a link for your convenience ( WWW.WWWW.WW au/docs/ACF3C8D.pdf). These help in both depression and anxiety and will also reduce the feeling of tightness. Best wishes. Dr Preeti Parakh MD Psychiatry

Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar

Follow up: Dr. Preeti Parakh (31 hours later)

Dr XXXXXXX You mean to take lorazepan 2mg in the morning, 1mg at 1pm and 1mg? Sorry for the misunderstanding but I cry most of the time during morning and afternoon? Now I"m taking the brand Wellbutrin Xl 300 mg for 2 days I fell anxious. What can I expext that the anxiety is going to get better or worse? Thank you, XXXX

Answered by Dr. Preeti Parakh (5 hours later)

Brief Answer: Explained below. Detailed Answer: Hi XXXXXXX I had advised dividing the total dose of 3 mg of lorazepam per day into three equal doses of 1 mg each as I had understood that you were having more problems at night. But if mornings and afternoons are the most difficult, you can continue with the current dosing of 2 mg in the morning and 1 mg at 1 pm. I feel that perhaps a hike in the dose of lorazepam is needed, as your evenings are not being covered for by the afternoon dose of lorazepam. If you could ask your doctor to shift you to clonazepam from lorazepam, a twice daily dosing would suffice as clonazepam is longer acting. Your doctor would not object as longer acting drugs are less likely to cause dependence and are considered safer. The worsening of anxiety is common when doses of antidepressants are hiked up. Hiking up lorazepam for the next few days can be done if needed. I expect you to feel much better within a week or so. Please do not worry. Things are going to get better. Best wishes. Dr Preeti Parakh MD Psychiatry

Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar

Follow up: Dr. Preeti Parakh (38 hours later)

Dr. Prieti, This is my day number 4 taking 20 ml citalopran, Wellbutrin 300mg, and 3 mg of lorazepan. Today I feel weak, fatigue, hopeless, crying spells almost all day (the crying spells I have no thought that make me cry are more physical symptoms or for no reason) as a side effect from welbutrin? Does wellbutrin help with physical symptoms(tight chest, tight troat, desconfort in my stomach? Thank you, XXXX

Answered by Dr. Preeti Parakh (6 hours later)

Brief Answer: As below. Detailed Answer: Hi XXXXXXX The physical symptoms are those of depression and anxiety only and all anti-depressants help by reducing depression. So, I do not feel that bupropion will not do the same for you. Please wait for a couple of days more and see if the symptoms start reducing or not. All antidepressants can lead to a worsening of depression and anxiety when a new one is started or the dose is hiked up, but this settles down in a few days. So you start improving in a couple of days. Please also do some relaxations excercises as I had mentioned earlier. These will help a lot. When you feel the tightness in chest and throat, taking a small dose of lorazepam will also help. Please hold on. This has to get better. Best wishes. Dr Preeti Parakh MD Psychiatry

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Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar