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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,
Asi
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,
Asi
Brief Answer:
Augmentation of wellbutrin is advisable
Detailed Answer:
Hi, thanks for writing through HCM.
I have read your query and understood your concerns.
Depression after particular stress is difficult to handle, until and unless the stressor is not bothering you anymore. If you have any feeling for your ex-girlfriend or your are thinking about her or missing her then it would make your life miserable. Let it go and start new life.
The side effects of wellbutrin are obviously very common but you can decrease side effects by taking after food in the morning. In resistance depression I usually prescribe combination of drugs like SSRI and wellbutrin, SSRI and SNRI, SSRI and mirtazapine. But in your case adding a SSRI will be more helpful. Prozac is not tried yet, so that would be wise move. But keep in mind that prozac can cause anxiety for initial one week. That is why I am giving my patients clonazepam along with prozac. Starting dose of it is 20 mg in the morning after breakfast.
Another SSRI would be paxil which has sedative effects also and it does not cause initial anxiety like prozac. It has to be taken at night and starting dose is 12.5 mg.
I don't think that seroquel will be helpful. If is primarily a antipsychotic, commonly used for bipolar depression. It can act as a anti-anxiety drug for short duration but not in long term.
Taking a antacid like pantoprazole 40 mg in morning before breakfast would be advisable in your case.
Help from a counsellor would benefit more your case as per my opinion because relapse is after the break-up, which contains emotional turmoil.
Hope I have answered your query. If you have further query then I shall be happy to help.
Wish you good health.
Augmentation of wellbutrin is advisable
Detailed Answer:
Hi, thanks for writing through HCM.
I have read your query and understood your concerns.
Depression after particular stress is difficult to handle, until and unless the stressor is not bothering you anymore. If you have any feeling for your ex-girlfriend or your are thinking about her or missing her then it would make your life miserable. Let it go and start new life.
The side effects of wellbutrin are obviously very common but you can decrease side effects by taking after food in the morning. In resistance depression I usually prescribe combination of drugs like SSRI and wellbutrin, SSRI and SNRI, SSRI and mirtazapine. But in your case adding a SSRI will be more helpful. Prozac is not tried yet, so that would be wise move. But keep in mind that prozac can cause anxiety for initial one week. That is why I am giving my patients clonazepam along with prozac. Starting dose of it is 20 mg in the morning after breakfast.
Another SSRI would be paxil which has sedative effects also and it does not cause initial anxiety like prozac. It has to be taken at night and starting dose is 12.5 mg.
I don't think that seroquel will be helpful. If is primarily a antipsychotic, commonly used for bipolar depression. It can act as a anti-anxiety drug for short duration but not in long term.
Taking a antacid like pantoprazole 40 mg in morning before breakfast would be advisable in your case.
Help from a counsellor would benefit more your case as per my opinion because relapse is after the break-up, which contains emotional turmoil.
Hope I have answered your query. If you have further query then I shall be happy to help.
Wish you good health.
Above answer was peer-reviewed by :
Dr. Raju A.T
Thsnks for the reply, first off i will mention that i do not miss my ex girlfriend at all or think about her, i have moved on and i am getting married in May this year. This isnt about my ex it was only a stressor but it seems like ny medication just stopped working. I did go to counselling and still am and its not helping at all. Iwas about to start sereqeul tonight actually as advised by my doctor, why do you think it will not help? Its FDA approved as an add on to anti depressant when its not effective so it seems like its exactly for that reason? Would it be best to add an SSRI at night to the wellbutrin? Is it worth trying to add cipralex again which stopped working for me after 11 years? I havent tried it in 8 months, is there a change along with wellbutrin it will help?
Brief Answer:
My advice is dependent on my personal experience
Detailed Answer:
Hi, thanks for writing again.
It is very good that you understand your problems and seek help. You have done lot to improve including the counselling and psychotherapy. Cognitive behavior therapy would be lot more helpful.
Now about the schedule of taking drugs. wellbutrin is not advisable to take at night because it causes insomnia and it has activating properties, same is true for prozac. Both of them must be taken in the morning. In my patients, if I am prescribing both of them, I advise them to take wellbutrin after breakfast and prozac after lunch. This is the best way to take these drugs.
Seroquel is though approved for add on in resistant depression, as per my clinical experience, I do not find helpful in your symptom profile.
As you have already tried pristiq and cymbalta, I don't think that other drugs like amitryptilline or imipramine can help. You can give it a try after discussing with your doctor. These TCA drugs cause severe side effects.
There is a study for treatment alternatives in resistant depression. The alternatives used are adding bupropion, buspirone, zoloft, pristiq, remeron, cognitive behavior therapy, thyroxin, lithium, lamotrigine etc.
If all of above fail then electroconvulsive therapy can be tried.
If cipralex is not working then there is no rational in starting again. It will be waste of time only. But with wellbutrin, studies show that it can work.
Hope I have answered your query. If you do not have further clarification then close the discussion and rate the answer.
Wish you good health and happy married life.
My advice is dependent on my personal experience
Detailed Answer:
Hi, thanks for writing again.
It is very good that you understand your problems and seek help. You have done lot to improve including the counselling and psychotherapy. Cognitive behavior therapy would be lot more helpful.
Now about the schedule of taking drugs. wellbutrin is not advisable to take at night because it causes insomnia and it has activating properties, same is true for prozac. Both of them must be taken in the morning. In my patients, if I am prescribing both of them, I advise them to take wellbutrin after breakfast and prozac after lunch. This is the best way to take these drugs.
Seroquel is though approved for add on in resistant depression, as per my clinical experience, I do not find helpful in your symptom profile.
As you have already tried pristiq and cymbalta, I don't think that other drugs like amitryptilline or imipramine can help. You can give it a try after discussing with your doctor. These TCA drugs cause severe side effects.
There is a study for treatment alternatives in resistant depression. The alternatives used are adding bupropion, buspirone, zoloft, pristiq, remeron, cognitive behavior therapy, thyroxin, lithium, lamotrigine etc.
If all of above fail then electroconvulsive therapy can be tried.
If cipralex is not working then there is no rational in starting again. It will be waste of time only. But with wellbutrin, studies show that it can work.
Hope I have answered your query. If you do not have further clarification then close the discussion and rate the answer.
Wish you good health and happy married life.
Above answer was peer-reviewed by :
Dr. Shanthi.E
Hello,
I am going to try adding serequel xr to wellbutrin xl and see if that helps, i want to confirm what you said about Cipralex, i know it doesnt make sense trying again by itself but adding it to wellbutrin would make sense to try? And would i need to take the ciprelex with wellbutrin in the morning? I would prefer to take it at night. would this combo be advised as the next move if serequel isnt helpful? I took first pill of serequel 50mg last night, how long does the sedative feeling during the day will last?
CBT never worked for me and i tried it for months. You mentioned different alternative drugs but not which combination of them? Did you mean all of them at the same time??
Lastly, since i never tried Prozac or Paxil by itself as one main pill, would it be recommended to try that if other things dont help before doing more combinations?
I am going to try adding serequel xr to wellbutrin xl and see if that helps, i want to confirm what you said about Cipralex, i know it doesnt make sense trying again by itself but adding it to wellbutrin would make sense to try? And would i need to take the ciprelex with wellbutrin in the morning? I would prefer to take it at night. would this combo be advised as the next move if serequel isnt helpful? I took first pill of serequel 50mg last night, how long does the sedative feeling during the day will last?
CBT never worked for me and i tried it for months. You mentioned different alternative drugs but not which combination of them? Did you mean all of them at the same time??
Lastly, since i never tried Prozac or Paxil by itself as one main pill, would it be recommended to try that if other things dont help before doing more combinations?
Brief Answer:
Adding cipralex to wellbutrin makes sense
Detailed Answer:
Hi, thanks for writing again.
Answering your questions accordingly.
1. Yeah, ciplralex alone has not worked in the second episode so it shouldn't be tried again but considering the guidelines for the treatment of resistant depression it can be effective when combined with wellbutrin.
2. Cipralex should be taken at night and wellbutrin in the morning.
3. I can not comment on which combination to start from the many available. In my patient I would have started cipralex and wellbutrin combination first. If it does not help within 4 weeks then you can change the drugs ans add some another from the list I gave you previously.
4. Initially seroquel can cause much sedation and it will decrease gradually but does not wean completely. Mild sedation will remain.
5. I mean combining any one of them with wellbutrin or cipralex. All the drugs can not be taken at same time.
6. After trying 2 SSRIs like cipralex and zoloft independently, I feel that they might not be effective but my clinical knowledge says that paxil can work. You can continue with wellbutrin and later on you can make changes and use paxil as add on to wellbutrin or use it independently.
Hope I have answered your query. If you do not have further clarifications then close the discussion and rate the answer.
Wish you good health.
Adding cipralex to wellbutrin makes sense
Detailed Answer:
Hi, thanks for writing again.
Answering your questions accordingly.
1. Yeah, ciplralex alone has not worked in the second episode so it shouldn't be tried again but considering the guidelines for the treatment of resistant depression it can be effective when combined with wellbutrin.
2. Cipralex should be taken at night and wellbutrin in the morning.
3. I can not comment on which combination to start from the many available. In my patient I would have started cipralex and wellbutrin combination first. If it does not help within 4 weeks then you can change the drugs ans add some another from the list I gave you previously.
4. Initially seroquel can cause much sedation and it will decrease gradually but does not wean completely. Mild sedation will remain.
5. I mean combining any one of them with wellbutrin or cipralex. All the drugs can not be taken at same time.
6. After trying 2 SSRIs like cipralex and zoloft independently, I feel that they might not be effective but my clinical knowledge says that paxil can work. You can continue with wellbutrin and later on you can make changes and use paxil as add on to wellbutrin or use it independently.
Hope I have answered your query. If you do not have further clarifications then close the discussion and rate the answer.
Wish you good health.
Above answer was peer-reviewed by :
Dr. Raju A.T
Thanks,
A few more questions:
I have been on Wellbutrin XR for about 3 and a half weeks and now at 300mg and even though i take it in the morning it still affects my sleep, i fall asleep but wake up around 6am and cannot falls asleep becsuse of the agitation and anxiety that wellbutrin is causing since i started it. I want to add Cipralex to it but will the wellbutrin side affefts of sleep disturbance and adding anxiety and restlesness subside? it only subsided a little bit in 3 weeks, 12 days at 300mg.
I dont want to take more clonazapam at night for sleep since i alredy take it during the day due to anxiety 0.5mg. How much longer should i stay on wellbutrintry if side affects of sleep problems and anxiety dont disipate? Will cipralex or Paxil as add on help with the anxiety or sleep?
Finally, if i cant tollerate wellbutrin due to side affects what would be best to combine Cipralex with instead?
A few more questions:
I have been on Wellbutrin XR for about 3 and a half weeks and now at 300mg and even though i take it in the morning it still affects my sleep, i fall asleep but wake up around 6am and cannot falls asleep becsuse of the agitation and anxiety that wellbutrin is causing since i started it. I want to add Cipralex to it but will the wellbutrin side affefts of sleep disturbance and adding anxiety and restlesness subside? it only subsided a little bit in 3 weeks, 12 days at 300mg.
I dont want to take more clonazapam at night for sleep since i alredy take it during the day due to anxiety 0.5mg. How much longer should i stay on wellbutrintry if side affects of sleep problems and anxiety dont disipate? Will cipralex or Paxil as add on help with the anxiety or sleep?
Finally, if i cant tollerate wellbutrin due to side affects what would be best to combine Cipralex with instead?
Brief Answer:
I prefer paxil for you
Detailed Answer:
Hi, thanks for writing again.
The schedule would be wellbutrin xl 300 mg in morning along with clonazepam 0.25 mg. At night clonazepam 0.5 would be great. It will also help in your sleep. The half life of clonazepam is more than 25 hours, if you take it at night then it will reduce anxiety during day time also and you shall feel much better. Give it a try.
For a person with significant anxiety I would prefer paxil over cipralex. Paxil would help more in anxiety. So it will be good drug for you.
I would prefer cipralex and pristiq if wellbutrin is to be stopped.
Changes are to be made only after visiting your doctor and discussing all these issues with him.
Hope I have answered your query. If you do not have further clarifications then close the discussion and rate the answer.
Wish you good health.
I prefer paxil for you
Detailed Answer:
Hi, thanks for writing again.
The schedule would be wellbutrin xl 300 mg in morning along with clonazepam 0.25 mg. At night clonazepam 0.5 would be great. It will also help in your sleep. The half life of clonazepam is more than 25 hours, if you take it at night then it will reduce anxiety during day time also and you shall feel much better. Give it a try.
For a person with significant anxiety I would prefer paxil over cipralex. Paxil would help more in anxiety. So it will be good drug for you.
I would prefer cipralex and pristiq if wellbutrin is to be stopped.
Changes are to be made only after visiting your doctor and discussing all these issues with him.
Hope I have answered your query. If you do not have further clarifications then close the discussion and rate the answer.
Wish you good health.
Above answer was peer-reviewed by :
Dr. Yogesh D
Could you please address the question regarding how long will it take for wellbutrin side affects as i described to subside? if they dont subside after 4-6 weeks should i stop this medication? Would it be still helpful if i lowered dose to 150mg to ease on side affects along with taking SSRI?
Also, since i have been taking clonazapam during the day everyday for maybe 4 months now i bulit some tollerance to it doesnt help me more than 4 hours, i dont want to increase the dose, taking 0,25mg has no affect on me at all and if i take 0.5mg at night when i wake up the affect is gone so i still get anxiety at work. Is it safe to take clonazapam for this long? i worry about dependense, will it be hard to wean off once i find a pill that helps my anxiety?
Also, since i have been taking clonazapam during the day everyday for maybe 4 months now i bulit some tollerance to it doesnt help me more than 4 hours, i dont want to increase the dose, taking 0,25mg has no affect on me at all and if i take 0.5mg at night when i wake up the affect is gone so i still get anxiety at work. Is it safe to take clonazapam for this long? i worry about dependense, will it be hard to wean off once i find a pill that helps my anxiety?
Brief Answer:
It can be stopped
Detailed Answer:
Hi, thanks for writing again.
I didn't answer that because I didn't get it as a question.
Side effects of wellbutrin does not last longer but they are still there in your case then I would suggest that wellbutrin doesn't suit you. Every person responds differently to one drugs. Some may have many side effects while other's can have none. I can not give absolute answer regarding when the side effects will subside. I do not have the answer.
My answer would be if wellbutrin is not making you better even by 25% then there is no need to continue the drug. If your symptoms, for which you have started wellbutrin, are not getting improved even by 25% then there are less chance that drugs will resolve symptoms after 3 weeks trial. If the drugs has shown response means decrease in the symptoms by 50% then the dose can be increased or another drug can be added to boost the effects. You can have your answer from this.
I would not allow my patients to lower the dose and wait. I would have stopped the drug and started the combination of other drugs [cipralex+pristiq]. I have already told you about paxil.
I have advised clonazepam differently because you were very much worried about your anxiety. If the anxiety is because of wellbutrin then stopping it would be the best option. You can take ambien 10 mg for sleep. I was increasing clonazepam for sleep as well as for anxiety. Taking benzodiazepin for long is not safe but when the condition is not improving then person has to take it for long duration under the observation of psychiatrist. Once your anxiety will be controlled, it will not be hard to wean off from clonazepam.
Discuss all of these with your prescribing doctor and I would advise you to visit a psychiatrist if you are not visiting one.
Hope I have answered your query. If you do not have further query then close the discussion and rate the answer.
Wish you good health.
It can be stopped
Detailed Answer:
Hi, thanks for writing again.
I didn't answer that because I didn't get it as a question.
Side effects of wellbutrin does not last longer but they are still there in your case then I would suggest that wellbutrin doesn't suit you. Every person responds differently to one drugs. Some may have many side effects while other's can have none. I can not give absolute answer regarding when the side effects will subside. I do not have the answer.
My answer would be if wellbutrin is not making you better even by 25% then there is no need to continue the drug. If your symptoms, for which you have started wellbutrin, are not getting improved even by 25% then there are less chance that drugs will resolve symptoms after 3 weeks trial. If the drugs has shown response means decrease in the symptoms by 50% then the dose can be increased or another drug can be added to boost the effects. You can have your answer from this.
I would not allow my patients to lower the dose and wait. I would have stopped the drug and started the combination of other drugs [cipralex+pristiq]. I have already told you about paxil.
I have advised clonazepam differently because you were very much worried about your anxiety. If the anxiety is because of wellbutrin then stopping it would be the best option. You can take ambien 10 mg for sleep. I was increasing clonazepam for sleep as well as for anxiety. Taking benzodiazepin for long is not safe but when the condition is not improving then person has to take it for long duration under the observation of psychiatrist. Once your anxiety will be controlled, it will not be hard to wean off from clonazepam.
Discuss all of these with your prescribing doctor and I would advise you to visit a psychiatrist if you are not visiting one.
Hope I have answered your query. If you do not have further query then close the discussion and rate the answer.
Wish you good health.
Above answer was peer-reviewed by :
Dr. Vinay Bhardwaj
Ok one last follow up in this case, i did start cipralex last night woth wellbutrin, if i stop wellbutrin i cannot add pristiq to cipralex becsuse i already tried pristiq by itself and it didnt help, i also tried cymbalta and it didnt help and gave bad side affects. Years ago i tried effexor and that didnt help, it was the first medication i tried before cipralex helped. So not much left to clmbine from SNRI, in such case what else could i combine to cipralex or Paxil if choose that?
Brief Answer:
Combination would help
Detailed Answer:
Hi, thanks for writing again.
You had pristiq and cipralex separately and you didn't improve. I am asking for the combination. It does not mean that combination won't benefit just because drugs weren't effective separately. They can be effective in combination, research trials have shown that.
Here are the few combinations to try:
1. Cipralex+mirtazapine
2. Cipralex+paxil
3. Pristiq+mirtazapine
4. Cipralex+pristiq
5. Effexor+mirtazapine
6. Cipralex+clomipramine
I hope that you can find a good drug combination from all of these. You can read about mirtazapine on the internet, it is also good drug. Paxil and mirtazapine both have calming effects so they help anxiety more.
Most important, why don't you try lexapro? It is a newer version of cipralex with better side effect profile. Think over it.
Make changes only after permission of your prescribing doctor.
Hope I have answered your query. If you do not have further clarifications then close the discussion and rate the answer.
Wish you good health.
Combination would help
Detailed Answer:
Hi, thanks for writing again.
You had pristiq and cipralex separately and you didn't improve. I am asking for the combination. It does not mean that combination won't benefit just because drugs weren't effective separately. They can be effective in combination, research trials have shown that.
Here are the few combinations to try:
1. Cipralex+mirtazapine
2. Cipralex+paxil
3. Pristiq+mirtazapine
4. Cipralex+pristiq
5. Effexor+mirtazapine
6. Cipralex+clomipramine
I hope that you can find a good drug combination from all of these. You can read about mirtazapine on the internet, it is also good drug. Paxil and mirtazapine both have calming effects so they help anxiety more.
Most important, why don't you try lexapro? It is a newer version of cipralex with better side effect profile. Think over it.
Make changes only after permission of your prescribing doctor.
Hope I have answered your query. If you do not have further clarifications then close the discussion and rate the answer.
Wish you good health.
Note: For further guidance on mental health, Click here.
Above answer was peer-reviewed by :
Dr. Vinay Bhardwaj
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