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    What causes persistent depression and anxiety despite taking medication?

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Posted on Mon, 31 Jul 2017 in General Health
Question: This is my second relapse and looks like just SSRIs aren't enough this time. I would say with:
1. 20 mg Escitalospram (SSRI).
2. 1.5 mg Clonazepam.
3. 50 mg Quitipine.
4. 150 mg Opipramol, and
5. 200 mg Modafinil
6. Just started with 150 mg of Velafaxine. ( 2 days now )
a day I am functional and living. If I divide my entire 24 hours:
1. 10 hours Sleep.
2. 1 hours normal to ok mood after I wake up in the morning.
3. 9 hours of "pure" depression and controlled anxiety (due to meds).
4. 4 hours of normal to ok mood before I go back to sleep.
Modafinil helped me feel motivated for 4 weeks but looks like that I have developed a tolerance towards it now. :(
This has been going for 5 months now. I won't say it "not-livable" but I won't call it a life, its just me a machine working working working all the time (mainly not to listen to my thoughts) for my family and with the hope that one day everything will be fine.
Please note: I very well know, understand and apply CBT and ACT therapies as well. They help me and keep myself aware, but as you know they are just coping strategies. I take 180 ml of alcohol once (sometime twice) a week to feel myself alive and powerful from inside so that I drag myself for the rest of the week.
I have been reading about Deep Brain Surgery, NSI-189 and other stuffs a lot and especially about you. This is my profile, please suggest me how can you help me?
doctor
Answered by Dr. Ashok Kumar 34 minutes later
Brief Answer:
I think we should wait for some more time

Detailed Answer:
Hello,
Thanks for using Healthcaremagic.

I read your query and understand your concerns.

From the available description I feel there is resistant depression as it is not having proper response with adequate dose of escitalopram and further augmentation with multiple medications in form of modafinil and quetiapine.

However to call for further strategy we should wait for at least two more weeks in hope that venlafaxine kicks in to help you in depression and have a life rather than just pushing through days. I think adding venlafaxine have merit as escitalopram helped you to some extent (partial response) and we need to keep this effect so the benefits offered by another medication (venlafaxine) helps in adding more benefit to the existing benefit.

In case there is no desired response over two weeks I think we can think of another mode of treatment such as rTMS or ECT if required. However I like to communicate that ECT have best evidence over the other mode of treatment and should be considered as treatment alternative in near future.

I hope this helps you.
Feel free to write back to me if you have more questions.
Thanks and regards.
Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar
doctor
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Follow up: Dr. Ashok Kumar 51 minutes later
During my first attack I was on medication and after a while when the symptoms receded I was just on 5 mg Escitalosparm and continued a good life for 2 years. Then I thought I was alright and hence stopped all meds. Immediately post 1 month I got my second attack (this feb) and continuing until now. Initially during my second attack this feb I tried to tackle my depression and anxiety without meds for a month. That was a horrible experience, anhedonia, derealization, depersonalization, emptyness like a hole in my heart and the feeling of getting inside a black pit. Then my doc said its time for antidepressants. From there on that severity is not there but 50% depression and anxiety remained. I work in big MNC in a top position, my son is 2 years old now, I dont know how can I function without meds. I am very scared of those horrible experiences.

Speaking about Modafinil it worked excellent for me for about 1 month, but I had to keep increasing its dosage from 100 mg, 150 mg, 200 mg and 250 mg. Then I understood its not the solution. So I am planning to reset my tolerance by having a week of "no modafinil". Hope it turns its honeymoon period back.

I consume 180 ml of alcohol once or twice a week to help me take out the frustration and feel motivated and powerful from inside for sometime, else I can't imagine going like this week after week. My doc says its ok, I hope it isn't harming me much? What do you say?
doctor
Answered by Dr. Ashok Kumar 6 hours later
Brief Answer:
180 ml per week is fine

Detailed Answer:
Hello,
Thanks for follow up.


First of I feel 180 ml of alcohol per week is fine provided it is not in form of binge drinking. I mean to say that limit your intake to 60 ml per day rather than taking the all on one day.

Regarding other experience I feel take a time before stopping modafinil as it is important to remain functional during this time. In case you have already decided I will recommend 100 mg of modafinil rather than 200 mg of modafinil for time being.

I hope this helps you further.
If you have any further query, I would be glad to help you.
In future, if you wish to ask any more questions, you can use the below-mentioned link to contact me.

http://doctor.healthcaremagic.com/doctors/dr-ashok-kumar/67386

Thanks and regards.
Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar
doctor
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Follow up: Dr. Ashok Kumar 4 hours later
Instead of reducing Modafinil I bumped the dosage by 50 mg more i.e. 250 mg. With that I see that my mornings are much bearable and I am interested in doing stuffs. I hope the Velafaxin kicks in before I run out of Modafinil 400 mg per day.
doctor
Answered by Dr. Ashok Kumar 59 minutes later
Brief Answer:
I hope same

Detailed Answer:
Hello,
Thanks for follow up.

Even I hope the same and request you to hold with same dose of modafinil for next two weeks.

Wish you great health ahead.
Thanks again.
Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar
doctor
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Follow up: Dr. Ashok Kumar 26 hours later
"First of I feel 180 ml of alcohol per week is fine provided it is not in form of binge drinking. I mean to say that limit your intake to 60 ml per day rather than taking the all on one day."

As per this suggestion of yours, taking 60 ml make me feel more bad, but once I cross 180 ml at once, depression have no place in my head anymore, and I enjoy, relax. socialize and plan for the next 3-4 hours before I sleep.

So its just one day a week (Saturday) that I take it once at a time, so that I have Sunday as a buffer for me.

That's my only hope for passing the week now. I spent the whole week thinking its ok I will have my time on Saturday. I hope this only hope of mine is also not adding to my problem?
doctor
Answered by Dr. Ashok Kumar 44 minutes later
Brief Answer:
Follow up

Detailed Answer:
Hello,
Thanks for follow up.

I understand that you are keeping alcohol as last but best remedy for ongoing depression but unfortunately the pattern of drinking is known to cause rebound depression for coming days.

It can be said that alcohol helps in depression but it brings more for the coming days and I think in this pattern a vicious cycle can be set leading to more problems than any benefit.

Above all the fact is scientifically proven that binge drinking deteriorates depression.

I hope this answers you further.
Thanks and regards.

Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar
doctor
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Follow up: Dr. Ashok Kumar 19 hours later
There is a little bit improvement in mood from the first time I messaged you, but I am not sure its due to the increased Modafinil (200 mg to 250 mg) or Venlafaxine (150 mg). How long will I be able to figure out if Venlafaxine is working for me?
doctor
Answered by Dr. Ashok Kumar 6 minutes later
Brief Answer:
Follow up

Detailed Answer:
Hello,
Thanks for reverting back to me.

Generally venlafaxine takes 10-14 days to have some improvement. The available research clearly indicates that by 2 weeks there is almost 20 % reduction in symptom severity.

Since we are interacting for last two to three days and you started venlafaxine recently I feel the observed positive effect comes from modafinil rather than venlafaxine at this stage. This is because positive effect of modafinil can be observed in two to three days itself.

I hope this helps you further.
Thanks and regards.
Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar
doctor
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Follow up: Dr. Ashok Kumar 17 minutes later
Just FYI I am on 20 mg escitalospram as well for the past 4 months. Just 20% reduction :( when should it work at its full potential? My anxiety has spiked due to my doubt on anti-depressants. Modafinil gave me a month of relief, but it also ditched me and I can not continue raising its dosage beyond 400 mg right? So its like a race for me now. What does your experience say, can TRDs like me live a more or less normal life with all the treatment options you guys have today?
doctor
Answered by Dr. Ashok Kumar 1 hour later
Brief Answer:
Yes it i possible

Detailed Answer:
Hello,
Thanks for reverting back to me.

Although it is difficult to treat treatment resistant depression but the available options today can achieve 100% success in depression. In my experience around 70 % of the individuals with final diagnosis of TRD can have normal life without any problem.

I agree that that the need for medications can be longer but it is does not mean it is end of life.

I also like to comment that your depression do not qualify with the diagnosis of TRD as there is incomplete response to one medication and have history of positive response in past which clearly indicates the little possibility of TRD, if any.

I hope this helps you further.
Thanks and regards.
Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar
doctor
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Follow up: Dr. Ashok Kumar 20 hours later
Thanks doctor for your replies, makes a lot of sense. I am planning to divide my alcohol intake into two days a week with 2 500 ml strong can beer per day. So if I calculate with 8% by volume of alcohol, in a single day I will consume:

2 x (8% of 500 ml) = 80 ml of alcohol per day, and
2 x 80 ml = 160 ml of alcohol per week.

Does this qualify as safe drinking for depressed people?
doctor
Answered by Dr. Ashok Kumar 12 minutes later
Brief Answer:
It is again No

Detailed Answer:
Hello,
Thanks for reverting back to me.

The safe drinking limit for alcohol is 24 to 36 gram of alcohol per day or 60-90 ml of 40% drink or 300 to 450 ml of strong beer.

I understand that it could be XXXXXXX for you but I recommended 60 ml on last occasion it was 60 ml of 40% alcohol concentration rather than 60 ml of absolute alcohol.

In my opinion have an effort to cut down on alcohol as it is going to help you in median to longer term although it have some setbacks in short term.

I hope this answers you further.
Thanks and regards.
Above answer was peer-reviewed by : Dr. Kampana
doctor
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Follow up: Dr. Ashok Kumar 2 days later
So I have been able to stop drinking this entire week without much craving. I visited NIMHANS yesterday and their the doctor said Modafinil was the cause of my downfalls. With every tolerance built on a dose I experienced a downfall, and since I was able to walk, talk and work so I should not have started on Modafinil at all. Anyways since now I am on 250 mg already, he has proposed me to taper down to 100 mg, 50 mg every 7 days.

He also said I should have tried with Escitalospram 30 mg before starting Velafaxin. Anways since I have already started for a week now, he said to continue the same 150 mg Velafaxine and also increase Escitalospram to 30 mg gradually in 4 days time.

Its 7 days on 150 mg Velafaxine now my overall state in 20% better than when I was only on 20 mg Escitalospram, should I give this credit to Velafaxine or the +50mg Modafinil?
doctor
Answered by Dr. Ashok Kumar 48 minutes later
Brief Answer:
Follow up

Detailed Answer:
Hello,
Thanks for follow up.

As communicated earlier if the response occured in a duration of two to three days the benefit probably came from modafinil.

If you feel that the response was not a sudden thing and it improved gradually I feel the credit goes to venlafaxine.

Having said this I like to inform you that you are at the best center of psychiatry in XXXXXXX and prefer following advice of NIMHANS unless otherwise there are compelling reasons.

I am also glad to know that you made a consistent effort to remove alcohol and currently abstinent over the one week without any problem or craving.

I hope this helps you further.
If you have any further query, I would be glad to help you.
In future, if you wish to ask any more questions, you can use the below-mentioned link to contact me.

http://doctor.healthcaremagic.com/doctors/dr-ashok-kumar/67386

Thanks and regards.
Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar
doctor
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Dr. Ashok Kumar

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