Brief Answer: Disturbed sleep pattern should change Detailed Answer: hello XXXXXXX welcome to hcm! On reading your query it becomes clear that the sadness part has improved with sertraline but the lethargy component is still there & sleep is disturbed. Firstly, i think that your lethagy and fatigue is related to the disturbed sleep pattern. You sleep late at night and therefore have fatigue all day long. In such cases i prefer giving a short and quick sleep inducer at night-which will help you fall asleep in time. So, you get up fresh in morning. Second approach is - we add modafinil in daytime to sertraline. This will reduce the fatigue and daytime lethargy and make you fresh and feel active. Please donot link the lethargy to sertraline, it is a left over component of depression. However, i personally feel that the first approach is better. Please ask if you have more querions for clarification Wish you good health. Dr. Manisha Gopal MD Psychiatry

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Brief Answer: wellbutrin may not help, reply some questions Detailed Answer: hello, Tell me few things- 1. for how long are you on sertraline? and if after reducing its dose to 50mg- how was the effect on sadness/ lethargy? 2. have you done your blood test- thyroid, vit. B12, and vit D levels? If yes, how are the results? 3. were at any time you into abusing drugs/ alcohol? The point that modafinil did not help leads us to depression as the only cause behind your lethargy..the depression ( including feeling of sadness is not 100% under control). Welbutrin will not help you much except in sleep/ anxiety..so, i dont think it will be worth trying in your case. I think that you should try to be busy all day long; get tired and sleep at 9 or -9:30pm; and even if you donot sleep at night-- try to remain awake the whole next day..then your natural sleep cycle will improve. When you sleep late-- get up late-- feel lethrgic all day long-- sleep or lie down in day time-- all sleep late again at night. So, we need to break this cycle. I hope you got the point. Please answer the questions to clarify some doubts in the case. Feel free to ask more questions if you have regarding this issue; i will be pleased to answer them. Dr. Manisha Gopal MD Psychiatry

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Brief Answer: may hike drug and add therapy Detailed Answer: Hello You can and should have been put on increased dose of sertraline (as this lethargy is a part of depression.). The point that you feel better as the day ends- point towards the particular phenomenon of endogenous depression where the patinet has worst hours of the day in morning and afternoon and as the day passes -he feel good about himself.. So, talk to your doctor about increasing the dose of sertraline- this will definitely help you. ( if there are no bothering side effects). Second- you can start the counselling sessions with your treating doctor twice a week to help you built motivation and add zeal to life. The cognitive therapy sessions help a lot when done.seriously. Please donot try to skip aftrenoon meals, but can take salads or fruits ( a light meal compared to full). you should go for walks / preefrably jogging in morning time. I know you will have to push yourself hard for this ...but this can change your life!! Please.ask.more queries if you have. Wish you good health! Dr. Manisha Gopal MD Psychiatry

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Brief Answer: may shift to mirtazapine/ venlafaxine. Detailed Answer: hello It is good to know that you are doing exercise daily, if you can.try out running or jogging in out doors- that is much better. II- If you want to try another medicine : i would completely support it point: as now i know that there had been no benefit even on 150mg sertraline- thereby making it useless to continue any more. So, dont add anything on it but shift / change the molecule only. If you ask me what should you go for, i would not perefer fluoxetine - as it may increase the anxiety. You can try mirtazapine- at night time ( it has intrinsic proeprty of giving sleep- thereby helping you fall asleep early). You have tried venalafaxine in insufficient doses ( only 75mg) - we can also plan to go for it inspite of mirtazapine. It is also one very good molecule and i have seen patiens responding very nicely to it in my practice. III- apart from exercise and proper & timely sleep; diet also plays a major role in handling depression. One should add more of salad servings-3/4 times a day and add walnut, sprouts in daily diet. Flaxseeds and almonds help to povide many essential micronutrient to our brain and help in early recovery. A daily dose of a good multi vitamin goes a long way in maintaing ones health. Wish you good health and speedy recovery. Dr. Manisha Gopal MD Psychiatry

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Brief Answer: add mirtazapine 7.5mg on sertraline. Detailed Answer: hello XXXXXXX You mentioned in your first query about taking 37. 5mg of venelafaxine twice a day without any results- so, i thought that this molecule can help. But as you went to higher doses without benefit, so that is now out of question. We have seen that only sertraline has helped you somewhere but no other drug. It will be worth a try to go for mirtazapine- starting with 7.5 mg added to sertraline itself. Then after a week increasing it to 15mg while keeping sertraline there ( as this drug atleast has some effect on you , so for some time i would suggest that you continue with it and just add other molecule..once the new drug shows response then we can.plan to bring down.sertraline). Now monitor the response on your mood pkus on lethargy and if there is benefit- increase mirtazapinee further and start reducing sertraline by 25 mg in one go. The highest dose of mirtazapine can be 45 mg. Taking it in evening hours-7/8 pm will help you fall asleep early. ##This (mirtazapine) may increase your appetite- so, keep a check on what you eat. I hope the reply helps you. Please feel free to ask any more detail about the drugs if something bothers you. I will be pleased to help. Take care Dr. Manisha Gopal

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Brief Answer: it is normal for mirtazapine initially Detailed Answer: Hello XXXXXXX Mirtazapine is sedative in nature and gives significant sleepiness to almost everyone.So, initially it is expected to do so even in your case. However, this sedative component goes away upto 50-60% within few days : varying from person to person. It is expected to give youvmore sleep as you already feel lethargic. It is recomended to try taking it for few days so that the sedative component comes down. You should take good amount of water all day long- sips every 10-15 minutes and more salads: these help in washing out of drug from body. Also, taking the tablet by early evening hours help in reducing sedation next day. It is expected that the sedation will reduce with each passing day. Hope the reply is helpful for you Do ask if there is any more query Dr. Manisha Gopal MD Psychiatry

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