Question: Hello,

I suffer from major depressive disorder/Anxiety, i really need some help and its hard to find a good psychiatrist that is taking new patients here in Toronto, Canada.

I am currently suffering from a relapse of my condition for just over a year now, first some history:

Originally my depression was first triggered in 2004 after doing ecstasy drugs (just once) and after a very difficult year of suffering i was put on Cipralex which saved my life! i went back to being normal and it worked for 11 years until Feb of last year, i went through a break up with my ex gf after 4 years of living together, as soon as she moved out the next day at work i noticed the symptoms coming back, the depression was deep and that cloud/fog and feeling of emptiness and no interest in anything, along with anxiety and physical symptoms such as shortness of breath, restlessness, shakiness, tight chest, that warm feeling in the pit of my stomach, feeling like a burning sensation on my skin. my depression manifests both mentally and physically unfortunately, and its a vicious cycle of being worse during the day and some relief at night. i have been working with my family doctor who originally helped me the first time around, we increased the dose of Cipralex but that didn't help, it seems like the Cipralex has 'pooped out' on me. in the following months i have tried Zoloft, Pristiq, back to trying Cipralex again to see if it will work but it didn't, than we tried Cymbalta and nothing was working. during this whole time i have been taking Clonazapam as needed to help take the edge off in order to somehow manage at work. i went off Cymbalta and decided to stay off meds for 2 months and tried something more natural like 5HTP and SJW but obviously it didn't help.

So, it seems like a case of treatment resistant depression. currently i am taking Wellbutrin XL and been on it for 3 weeks so far, the side affects have been really hard, mainly stomach pain, increase in anxiety and insomnia, i can fall a sleep but cannot stay asleep and feel agitation and restlessness. i started at 150mg for 12 days and went up to 300mg and have been on that dose for about 9 days now. the side affects have subsided a little bit although i still cant sleep much even though i take the medication in the morning.

it hasn't helped so far and im not sure it will but i will give it more time just to be safe around 4-6 weeks.

I am really frustrated and my life is on hold for over a year, i cant believe this illness is back and im not able to get back to myself, don't know why my meds just stopped working and im starting to feel hopeless but im determined to find the right combo.

I saw my doctor this week and he suggested adding Serequel XR as an add on to Wellbutrin, another option was to add an SSRI to Wellbutrin as a combination strategy. i dont know if there's a point in trying other SSRI's that i haven't before such as Prozac?

Im sorry for the long message but im really desperate, i am getting married in May and i cant even enjoy the planning and just living one day at a time.

based on all the history and what i have tried including the recent suggestions from my GP, what would you recommend as the next step? or the next few options just to know what else i can try.

Thanks,

XXXX

Thank you for the reply, i want to clarify a few points:

First, i decided to try Serequel XR as add on to Wellbutrin, i started last night at 50mg and today i feel very out of it and sedated, i understand this is a side affect of Serequel, how long will this affect last? How long should i try this augmentation to know it if works?

As for TCA, i understand they have bad side affects snd also interact with lots of food? I would prefer not to try that. I did try mirtazapine before as add on to Cipralex for about 3 weeks and it didnt help, was this not enough time? It knocked me out everynight when i took it and didnt like that.

I am already taking clonazapam 0.5 mg a day during the day just to take the edge off at work, CBT has never worked for me, tried it before and im still in therapy but dont find it helpful.

I recently did blood work that included vitamin B12 and levels are normal, also did a thyroid test TSH which was also normal but should i still do a full profile thyroid test?

Also, what about the option of combining an SSRI with the wellbutrin? would that be advised?

Thanks,

As for TCA, what are the common side affects? Are there some foods that need to be avoided ehen using TCA? and which TCA is most effective if i decided to try it?

I have decided not to continue serequel for now and may try it in the future if other combination doesnt work.

As for prozac and wellbutrin, i understand that like wellbutrin prozac should be taken in the morning as both are stimulating? I really prefer to take meds at night. so far after 3 and a half weeks of wellbutrin the side affects are still bad, mainly sleep disturbece in the morning due to agitation and increased anxiety from wellbutrin, even when i take it in the morning it still disturbs my sleep, i feel that adding prozac may just intensify this. How long does it take for side affects of wellbutrin to subside? its causing more anxiety and agitation and i have to take more clonazapam and i worry about dependense to it. Wellbutrin causes stomach pain and nausea, these side affefts are a bit less severe in recent days but still present, does it even go away?

What about adding Cipralex to Wellbutrin? This is what i want to start right away. I know cipralex stopped working for me but can it work better combined with wellbutrin? Or maybe adding Paxil to wellbutrin? i never tried Paxil, perhaps even try it as a stand alone pill?

If i do add cipralex or other SSRI to wellbutirn will it be effective if i cut the wellbutrin dose to 150mg due to the strong side affects or is that not high enough dose in my case?

Lastly, you mention adding lithium, i understand this should be a last resort as long term csn be dangerous? what would lithium be added to?

Thanks!

Thanks again for the reply, the information you provide makes sense and i appreciate the help.

I will definitely need to confirm the diagnosis of melancholic depression as you suggested since from reading about it, it does mention that TCA are more effective however how does that explain the fact that Cipralex did work for me for 11 years?

Also can imipramine be taken as a stand alone medication or is it added to other medication? if so which one?
Also, is it true that TCAs are more for older people? I'm 35. i will definitely try it, it could be that i have been trying the wrong options but based on past i only seemed logical to my doctor, he knows about my condition being worse in morning/day and better at night but when i described it he diagnosed as MDD.

As for serequel i have only taken 1 pill 2 nights ago so I'm sure its safe to stop it right away, the night after i added Cipralex to Wellbutrin so i will see how this combination works for a few weeks, i will lower Wellbutrin to 150mg and slowly increased cipralex from 10mg to 20mg but again i want to make sure that wellbutrin 150mg is even effective enough along with Cipralex? otherwise no point to reduce.

why is it better to change Wellbutrin schedule to daytime instead of morning? what time of the day do you mean? i worry that since its affecting my sleep the earlier i take it the better it is to avoid these symptoms no?

as far as clonazapam, yes i have been worried about dependence and that caused me to always worry before i take it instead of just getting the relief because i will take it anyways. at this point clonazapam isn't as effective after a few months of taking 0.5mg each day, i take it in the morning and the effect only lasts for 3-4 hours, would it be safe to add 0.25mg and take total of 0.75mg to get some more relief? and taking 0.5mg at night for sleep plus 0.5-0.75mg during the day isn't too much? will i still be able to safely wean off when time comes?

finally, i would like your advise as for what would be best to try next incase the wellbutrin / Cipralex combo does not work?

Thanks as always!

Thanks,

Just to confirm, i have always taken wellbutrin in the morning and still so far it csuses sleep disturbance, you mentioned to take it during the daytime, did you mesn morning or later in the day sometime?

Clonazapam 0.25 at noon will not affect me at all at this point, only 0.5mg helps a little bit as i have alrady developed tollerance. How long should i wait to see if Cipralex/Wellbutrin combo will work?
Sorry, i forgot to also ask one other thing.

for the past 3-4 months i have been having constant nausea, more in the morning and during the day, it gets better in the evening, kinda like my depression symptoms. when i had depression before nausea wasn't a side affect, this started after i tried Cymbalta 4-5 months ago and it caused major nausea side affect and after i stopped this medication until now i still suffer from nausea, sometimes its worse sometimes not so much but its always there. is this something to concern as far as physical underlying issue? any test is recommended to rule out some Gastrointestinal issues?

Thanks.

I feel like i must take clonazapam 0.5mg in the morning when i get to work to ease my symptoms i cant wait till afternoon, wellbutrin makes me agitated and adds more anxiety, should i also add 0.25 in the afternoon? Becsuse 0.5mg already wears off by lunch time.

Since taking wellbutrin i have lost about 5-6kg in 4 weeks is that too much? After cymbalta i stopped all meds for anout 2 months and still had nausea, could nausea be side affect of clonazapam also?

I resuced wellbutrin to 150mg and noticed that on second day nausea is worse in the morning and feel more shaky / agitated is thaa normal due to change in dose? Also, how many days should i wait before increasing cipralex from 10mg to 20mg?

What causes the weight loss from wellbutrin? Is it the medication itself? Or the lack of appetite and eating less? I actually eat pretty much the same but still lost weight so is there something that the pills are doing in the body chemically to lose weight?

I understand and it makes sense.

another thing i wanted to confirm, you mentioned that the type of my MDD is melancholic, i looked into this type of depression and the characteristics and i don't have all of those symptoms as described, for example it says that melancholic depression is typically for bi polar which i am not, also says one symptoms is over sleeping, i have insomnia so i wish i had this problem of over sleeping. also it does say symptoms are worse in the morning which is correct in my case but it also says it gets better through the day, that not the case with me, my symptoms are pretty much constant during morning and day and only get some relief at night time. is it possible that this diagnosis isnt 100%?

Thanks for the information and quick response.

If i want to stop Wellbutrin due to side affects and add something else to Cipralex while i try it, what would be recommended ? something like Serequel or maybe some other Antidepressant?

also, is it beneficial to take more than 20mg cipralex if that doesn't show effective considering its the highest recommended dose?

Thanks, and if i decide to stop wellbutrin XL, how would the taper schedule be? now i am back on 150mg for a few days, since there is no smaller dose, when do i just stop it?
Also, is there something i can take for the Anxiety instead of replying on benzo pills? something that is not addictive?

Thanks, yes paroxetine which is Paxil is something i was thinking to ask my doctor about trying next as a stand alone pill since i never tried it, is that a good idea? is it correct that Paxil is also sedative and helpful with sleep?

Would Paxil be prefered over Prozac in my case which i also never tried? I believe prozac has similar affect as stimulant like wellbutrin and is taken in the morning? so i would assume it might cause similar sleep and anxiety side affects for me.