Brief Answer:
Different options suggested.

Detailed Answer:
Hello and welcome to Healthcare Magic. Thanks for your query.

I understand that you are suffering from GAD and Depression and have been tried on different antidepressant / anti-anxiety medication without much success. From the details that you have provided, I can seen that you have been tried on different classes of anti-depressant medication:

SSRIs - Celexa (Citalopram) and Paxil (Paroxetine)
SNRIs - Cymbalta (Duloxetine) and Effexor (Venlafaxine)
NaSSA - Remeron (Mirtazapine)

In such a case there are the following treatment options available:

1) To switch to a different medication - the available ones that can be beneficial are:
- Bupropion (Wellbutrin): This medication acts on a different brain receptor and can be quite effective when other classes of medication have failed. It also has relatively lesser side effects (and is especially preferred because it doesn't have sexual side effects which most anti-depressants can have).
- Fluvoxamine (Luvox): This is an SSRI anti-depressant / anti-anxiety medication and can be tried if other SSRIs have not proven effective. It is particularly effective in persons having recurrent anxious thoughts or obsessive type of thoughts.
- As a last resort MAOIs like Phenelzine (Nardil) can be considered. But the dosing and monitoring has to be carefully done as there are chances of drug interactions and adverse effects. Neverthless, it is a very effective class of medication, especially for treatment-resistant depression.

2) The other option is to "augment" your anti-depressant medication with Lithium or T3 (Tri-iodothyronine). This is a proven and effective treatment strategy in persons with resistant depression and has been recommended as an option by international guidelines.

3) Another effective option is to combine medication with psychological therapies such as CBT. This has been proven to improve the overall outcome / success rates.

Regarding your anxiety symptoms, another medication that can be considered instead of Klonopin (Clonazepam) is Buspirone. This is a non-benzodiazepine anti-anxiety medication, which means that it does not have a risk for addiction or other side effects associalted with benzodiazepine medication.

So, I would suggest that you discuss all the above options with your doctor and make an informed and joint decision regarding the next treatment option.

Wish you all the best.

Regards,
Dr. Jonas Sundarakumar
Consultant Psychiatrist

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Brief Answer:
Need details about the current dose / duration...

Detailed Answer:
Hello again,

There is a good likelihood that Bupropiaon may work now, if it has worked before. But you may require a higher dose to sustain the improvement.

Regarding the sexual side effects of SSRIs, unfortunately, all SSRIs have the more or less the same degree of sexual side effects.

The decision on whether to increase the dose of Cymbalta or switch to a different anti-depressant will depend on what dose you are currently on and how long you have been on that dose. So, please let me know these details, so that I can opine on this decision.

Regards,
Dr. Jonas Sundarakumar
Consultant Psychiatrist

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Brief Answer:
Can try increasing the dose of Cymbalta...

Detailed Answer:
Hi XXXXXXX

Considering the following facts...

- that you have been tried unsuccessfully on several anti-depressants (and have not tolerated some medication also),

- that you seem to be having some response (though not satisfactory) to Cymbalta,

- that the dose of Cymbalta can be increased upto 120mg per day,

...my opinion is that it would be wise to first try an increase in the dose before jumping to a decision to change the medication. Moreover, there is no sureity that the new medication would be better or more tolerable than the previous different medication (and the choices available at this point are rather very limited)

In my clinical experience, I have seen that many persons who are 'partial responders' show further improvement when the dosage is increased to maximum (though I don't usually go more than 100mg of Duloxetine).

So, I would recommend that the dose of Cymbalta can be increased to 80mg initially (for about 4 weeks) and if needed, increased further upto 100mg. The total dose can be divided into twice-a-day dosing, in order to reduce the risk of side effects.

Regards,
Dr. Jonas Sundarakumar
Consultant Psychiatrist

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