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Suggest treatment for severe depression, chronic tension headache and neck stiffness

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Posted on Sat, 30 May 2015
Question: Dear Madam
Thanks a lot for your response to my query. I m currently 44 years old and I had a very severe bout of Depression suddenly,one fine morning when I woke up in March 1994 i.e. 21 years back when I was doing my engineering.
Prior to this episode
I had problems of chronic tension headache, stiffness in neck with tics whenever I used to bend my neck either side for relaxing, constant head pain on entire head ,lot of pain in eyes and habit of pulling hair (trichotillomania) for almost 5 years. But I igonred these symptoms and used to concentrate only on studies as I used to be very good at studies inspite of all these problems.But one thing I used to constantly observe is a gradual decrease in my memory because of constant headache,stiffness in neck and pain in eyes before precipitating in to severe Depressive attack. After I experienced the Depression attack which made me completely numb,brain fog,severe fatigue,experiencing loss of balance while walking,severe memory loss(otherwise I used to have sharp memory as a student and used to be topped in school throughout) and dis interest in almost everything which made me feel like sleeping almost entire day.I started having excessive sleepiness throughout the day but without any freshness or energy after waking up.After I met a psychiatrist I was put on flunil 20 twice daily along with Evion 400 the condition improved slowly but I only to 20% of what I was earlier.I took this medication for almost 1 year and later tapered slowly,whenever I used to be off on medication for few days again I used to get back my problems of brain fog,severe fatigue etc and I used to resume the same and meanwhile I met
another doctor he put me on tricyclics(priohiaden ,demolox etc) along with flunil for 6 months , since tricyclics used to make me very drowsy and tired I tapered tricyclics gradually and continued with Flunil 40mg.

Before the start of this major Depressive episode I used to be at at my best mentally,physically and sexually, but even though I m on medication since long I
Still I experience lot of fatigue, sleepiness,lack of libido n erection issues and body pains especially weakness in legs and neck stiffness(psychosomatic) and sever memory problems etc.
I used to have excellent sharp memory before major depressive episode
.Kindly advise whether anyother drug combination with Flunil 40 mg work to improve my condition. Later from Blood tests I found to habe B12 and Vit D deficiency for which I was put on Vibrania D
Background: I used to be topper in academics with excellent n sharp memory numerals,,resoning etc good energy n good libido before the major depressive episode

My current medications are Morning 9am Duzela 20mg(using only since last 8 weeks) and Vibrania D, Lunch -Flunil 60mg.I have attached my recent blood tests reports also which are quite normal, no problem of thyroid,sugar etc.
My current problems are major impairment in cognition related issues and constant fatigue.
1-Brain fog,/ constant low mood/dullness 2-Memory Problems(short term predominantl) 2a-numerals unable to remember 3-Severe fatigue ,4-Lack of motivation and energy,5- weakness in legs improved slightly after Vit D+B12 (vibrania D) combination , 5-Libido and erection issues,
Since I have been using Flunil for almost 20 years, kindly advise any add on medication to improve my condition along with Flunil or change in medication as I am hesitant to move out of Flunil as my body accustomed to this medicnine since long.I really appreciate your way of analysing my problem. I am sure you can certainly pull me out of this problem.I m currently working and staying in XXXXXXX and well place in Govt sector because of my good academics.Mob no:0000.Thanks and Regards-XXXX

doctor
Answered by Dr. Manisha Gopal (5 hours later)
Brief Answer:
paroxetine will help. duloxetine can be stopped

Detailed Answer:
Hello,
Thanks for writing the query and having trust in me. I will try my best to solve your issue.

Let me first spell out your problems:

You have depression from past 21+5 yrs. ( though less in intensity initially)
.
- you presently have less problems but have never been asymptomatic in these past several years.

- have been on flunil 40-60mg from the start. You have been on some other drugs but flunil had been there.

- had vit d deficiency and were treated for the same with vibrania.

You want to continue flunil as you never left it. So, we have to think of some add on right now and if you feel good, you may taper flunil willingly.
Personally I feel flunil is quite an old molecule and there are far beter choices available now a days.

In cases like yours I would have stopped duloxetine 20mg ( as it is not very effective or useful) and start paroxetine 12.5mg and increase to 25mg after a week.

I think you will start feeling better in 1-2 weeks of starting this drug. It is also given in cases of premature ejaculation and has less sexual side effects.

Apart from the medicines- get vit B12 levels done. If less than 500-600mcg, B12 supplementation will be needed. They are very effective in treatment.

All your present symptom of lack of energy, short term memory loss ( you dont really need citicoline as there is no memory issue really...its only due to depression), low mood, anhedonia, low libido etc., are part and parcel of depression. All of these will improve with treatment.

Try to join gym or at least jog or join swimming if possible. You need to go out as this will help in recovery.

cut down on tea, coffee and cold drinks. And stop tobacco, alcohol if you use them.

I also need to know if you have any family history of depression or anxiety?

Your problem is not very big but has been there for long time. It can get better, dont worry.

Wish you good luck.
Please ask queries for any clarification and also answer my queries in detail.

Dr. Manisha Gopal
MD Neuropsychiatry
Above answer was peer-reviewed by : Dr. Shanthi.E
doctor
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Follow up: Dr. Manisha Gopal (3 hours later)
Dear Madam, thanks a lot for reassuring mail.I m wiling to drop duloxetine, even I never noticed any improvement, eventhough it is 7 weeks since I started using it. If you wish you can taper Flunil also gradually as you feel it is a old molecule because depression for more than 20 years is too big a time .Regarding B12 I got it tested and I found deficient in B12, that's the reason I was prescribed Voibrania D (which is combination of 1500mcg B12+1000 IU VitD).Infact the most prominent issues of priority are 1-Memory impairment (I used to have excellent sharp memory before depressive episode),2-Lack of motivation and severe body fatigue, 3-constant Brain fog/dullness, I never felt high energy n high mood after the depressive episode.
I m open for anything which you feel best for this kind of long duration depressive cases as it has decreased my zest for life.
Kindly provide prescription medicine regime to be followed from tomorrow as I want to start as early as tomorrow.
Kindly provide medication in the next mail..Regards, XXXX

As per my knowledge, there is no known family history of Depression. I daily do yoga n walking for almost 1 Hour. I feel personally chronic tension headaches and stress led to depression as I always used to be very ambitious in studies and aim to be the best in all other things I used to practice like cricket,essay writing,carroms etc .I m tee totaller and pure vegetarian.
doctor
Answered by Dr. Manisha Gopal (43 minutes later)
Brief Answer:
in comorbid headaches- venalafaxine is very good.

Detailed Answer:
Hello,

Good to know that you are doing some lifestyle managment practices like - yoga and walk and you are a teatottler.
Please continue the same.

As per my opinion you can stop duloxetine from tommorow. Take flunil for now as it can be stopped suddenly ( this molecule does not need any tapering as it has a long half life). So,it can be done anytime.

You havent specified the issue of headache previously, this is common comorbidity in depressive disorder.
In such cases where head ache is also a prominent problem along with symptoms of depression- I prefer venalafaxine ( it is better compared to paroxetine; else both molecule are equally good).

For in between episodes of headache- you can use naxdom ( naoroxen sodium with domperidone) 500mg on SOS basis. Take the medicine within 5-10min of starting of headache. Dont try to tolerate the headache for sometime, as then the headache dosent go completely with any drug. With time these headaches will stop.

Try to take nuts ( walnuts and almonds) on daily basis.

Venelafaxine can be started in a dosage of 37.5mg after breakfast; increase by another 37.5mg after one to two weeks. Maximum dosage can go upto 225mg.
Once you feel that you are having improvement- stop using flunil.

Ideally you should take injections of vit B12. It is better and more effective. Oral regimen takes lot of time.

Vit D also should be taken 60K IU XXXXXXX per week for eight weeks;then 1000 IU per month for next 3-6 months. Take calcium daily along with vit D regimen.

You can start the medicine but get serum electrolytes levels also done in a day or two.

If you want to discuss the case further, try to do so in about one week or ten days after starting venelafaxine. I hope by that time there will be some improvement and by seeing your recovery I will be able to guide ahead properly.

Hope the reply helps you to get better.
wish you speedy recovery!

Dr. Manisha Gopal
MD Neuropsychiatry



Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar
doctor
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Follow up: Dr. Manisha Gopal (41 minutes later)
Thanks madam for your prompt reply.I have taken 60k IU XXXXXXX per week for eight weeks as per the course and continuing with 1000 IU regime.Serum electrolyte levels are there any specific parameters to be checked ? please let me know.After starting antidepressant medication my bouts of headaches reduced considerably I experience only now and then, not much.What is the brand name of venalafaxine
to be bought in chemist shop? Whether I should go for immediate release or XR(Extended release ) tabs pls let me know.Regards
doctor
Answered by Dr. Manisha Gopal (10 minutes later)
Brief Answer:
veniz xr or venlift OD

Detailed Answer:
Hello,

Serum electrolytes should include sr. Sodium, potassium,chloride and magnesium. These are necessary and rest you may add if you want.

venalafaxine is available in many names- veniz XR ( sun pharma) or venlift od ( torrent). Both are capsule formulations and extended release. There is no plain preparation. Both are good brands.

Im happy that your headaches are helped by your current meds and it is just occasionally that you have them. Still, venalafaxine can be the first choice in someone who is prone for them.
and you can use naxdom on SOS basis.

Get the vit D levels done again and see how the levels are presently. Sometimes one needs to repeat or extend the 60K sachets in case the regimn does not raise the levels sufficiently.

And similarly, take supplement of B12 and then repeat its level too.

Good luck.
Dr. Manisha Gopal
Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar
doctor
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Follow up: Dr. Manisha Gopal (11 hours later)
Madam, Thanks a lot I got both B12 and Vit D tests done and both the results are within limits but still I m continuing using Vibrania D.Serum levels results I will update u as soon as I get it done.My first depressive episode is so severe that i felt it is a case neurological problem related to brain some thing like haemorhage, but psychiatrist ruled out n put me on Flunil

Madam How do I increase dosage i.e initially37.5 mg for 1 week and the 75 mg for how long ? are there any side effects? is there any problem in stopping duzela 20 suddenly and using veniz xr in ints place pls let me know.Regards
doctor
Answered by Dr. Manisha Gopal (6 hours later)
Brief Answer:
stopping duzela is ok; start veniz..no issue

Detailed Answer:
Hello,

There is no problem in stopping duzela 20mg...start veniz xr 37.5mg.

increase veniz to 75mg after a week and then we need to see how much more you need and how much added response it gave you. It is difficult to predict it right now.

I dont have any problem in telling anything regarding the dosage but, I cant do so at present...until you start the med and we see the initial repsonse atleast .

Dont worry, you may continue veniz at 75mg for few months if that makes you feel completely ok.

Once you start feeling better, stop flunil.

Dont be scared, changing medicines or switching over to other drug in case of non response or less reponse is not uncommon.

Wish you good health.
Dr. Manisha Gopal

Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar
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Suggest treatment for severe depression, chronic tension headache and neck stiffness

Brief Answer: paroxetine will help. duloxetine can be stopped Detailed Answer: Hello, Thanks for writing the query and having trust in me. I will try my best to solve your issue. Let me first spell out your problems: You have depression from past 21+5 yrs. ( though less in intensity initially) . - you presently have less problems but have never been asymptomatic in these past several years. - have been on flunil 40-60mg from the start. You have been on some other drugs but flunil had been there. - had vit d deficiency and were treated for the same with vibrania. You want to continue flunil as you never left it. So, we have to think of some add on right now and if you feel good, you may taper flunil willingly. Personally I feel flunil is quite an old molecule and there are far beter choices available now a days. In cases like yours I would have stopped duloxetine 20mg ( as it is not very effective or useful) and start paroxetine 12.5mg and increase to 25mg after a week. I think you will start feeling better in 1-2 weeks of starting this drug. It is also given in cases of premature ejaculation and has less sexual side effects. Apart from the medicines- get vit B12 levels done. If less than 500-600mcg, B12 supplementation will be needed. They are very effective in treatment. All your present symptom of lack of energy, short term memory loss ( you dont really need citicoline as there is no memory issue really...its only due to depression), low mood, anhedonia, low libido etc., are part and parcel of depression. All of these will improve with treatment. Try to join gym or at least jog or join swimming if possible. You need to go out as this will help in recovery. cut down on tea, coffee and cold drinks. And stop tobacco, alcohol if you use them. I also need to know if you have any family history of depression or anxiety? Your problem is not very big but has been there for long time. It can get better, dont worry. Wish you good luck. Please ask queries for any clarification and also answer my queries in detail. Dr. Manisha Gopal MD Neuropsychiatry