Brief Answer:
need some details.

Detailed Answer:
Hello Mr. XXXXXXX
Welcome to HCM.

I have read your query and understand your concerns.

It would be very kind on your part if you can please give some more details:

1. Since how long have you been taking this dose of sertraline 100mg?
Have you tried dose increments with any improvements?

2. The lethargy, fatigue, disturbed sleep-wake cycle and amotivation which you have mentioned are developed after treatment or were present even before treatment?

3. At what time of day you take sertraline?

4. At what time of day you exercise? morning or evening?

5. Do you take alcohol or smoke or any drug of abuse?

6. What is the reason of sleeping late? Do you have problem in initiation of sleep? or some other reasons like work, stress etc?

Methylpehnidate has been traditionally used as an augmenting agent in poor responders to antidepressants.
But, it has abuse potential and studies show that it does not lead to significant improvement.

Similarly, reboxetine is also a novel drug with doubtful efficacy.

Before this, there are other drugs which can be employed in improving such symptoms.

The answers to above questions will help me a great deal to choose a right drug for you.

Hope to hear from you.

Thanks.

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Brief Answer:
sleep hygiene; aripiprazole

Detailed Answer:
Thanks for the details.

Dear Mr. XXXXXXX
I have gone through the details thoroughly.

I have some suggestions for you which you may find helpful:

1. You are having fatigue and lethargy even before illness. You take sertraline at 9 a.m. The sedation caused by sertraline is variable and varies from individual to individual.
First, I would suggest you to take sertraline at bedtime.

2. You have to work on your sleep cycle.
Follow these sleep hygiene tips:
Avoid daytime naps.
Avoid late night work.
Do not take heavy fatty meals in dinner, tea, coffee at bedtime.
Take a glass of warm milk before going to sleep.
Take warm water bath in before going to bed.
Do not exercise in evening. Try to go for a morning walk preferably.

3. You have tried wellbutrin and prozac with no benefits. Armodafinil and modafinil cause side effects.
If these activating drugs are not working for you, I would suggest addition of aripiprazole to your antidepressant sertraline.
This is a prescription drug and is a antipsychotic. However, in low doses (say 5-10 mg) it acts a wonderful augmenting agent to antidepressants and is an activating drug. This will lift your mood and lessen your fatigue and lethargy.
Also, it does not cause weight gain and sedation.

4. Sweating may not be due to sertraline.
I would advice you to drink lots of water to avoid dehydration.

Methylphenidate has addiction potential. So I would not recommend its usage.

Kindly discuss these issues with your psychiatrist.

Hope this helps.

Feel free to ask further.

Thanks.

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Brief Answer:
aripiprazole to be taken in morning.

Detailed Answer:
You are most welcome :)

Symptomatically, depression can be divided into reduced positive affect and increased negative affect.

I think your symptpms fall into the first category of reduced positive affect which include low motivation, reduced energy, low interest.

For such symptoms, usually wellbutrin works well but has not worked for you.

Then in such cases, I usually prefer to use aripiprazole in doses of 5-10mg depending on patient's response.
It takes 2-4 weeks to show its effects.
The drug is usually safe and does not cause weight gain. There are no serious side effects.
Initially, it can cause slight restlessness and nausea which resolves in few days.
It is to be taken in morning time.

Exercises are just supplementary to medicines. You have to continue them to have their benefits, if any.
Practice deep breathing and meditation.
A morning walk of 30 minutes daily is also helpful.

The treatment of depression and response to drugs varies from person to person.
The correct treatment for depression is antidepressants and you are receiving that.
Its just that some people respond early and some late.

You can read some motivational stories to increase your motivation.
Indulge yourself in your hobbies.
Try gardening, painting, watching movies or anything which you like.
Set small targets for the day and try to accomplish them. This will make you feel confident.

Try these suggestions.
Discuss the above issues with your doctor.

You will be definitely benefitted.

Hope you find my suggestions helpful.

I wish you good health.

Thanks.

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Brief Answer:
nausea may last upto 7 days.

Detailed Answer:
Hi again.

Happy to know that you are feeling better with aripiprazole.

Nausea with this drug is common and usually resolves in 3-4 days in most cases.
In some cases, this may last upto 7 days.
May I please know, how much dose of aripiprazole are you taking?
Is nausea bothering you a lot?

Please continue with the rabeprazole and domperidone combination. (I hope this combination contains domperidone in sustained release form).

For the problem of gas, rabeprazole should work.
Also, drink lots of water and avoid fatty food.

For losing weight, try following tips:
1. Drink a glass of water half an hour before meals.
2. Cut down the starch and sugar rich foods. Increase proteins in your diet.
3. Eat fibrous foods like cucumber, carrot etc.
4. Continue with your brisk morning walk 30 minutes each day.

You are having bothersome sweating. It is possibly another side effect of sertraline. For this, drug oxybutynin (prescription drug) in low doses of 5mg/day work well as this is an anticholinergic drug. Kindly discuss this with your doctor and start the drug after his advice.

Hope this answers your query satisfactorily.

Take care.
Thanks.

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Brief Answer:
dose increment needed.

Detailed Answer:
Hello Again.

You have been taking 2mg of aripiprazole since last 15 days almost (we had conversation 15 days back and you started aripiprazole).

I would suggest a dose increment to 5mg.
2mg is the very minimal dose.
As you are responsing to the drug, I think you will have more improvement with dose increment.

In my opinion, you should increase the dose to 5mg and take it for another week. Observe the response in your body.
Aripirazole is very slow to act.
But kindly keep your doctor informed about this.

Joint pain is not the side effect of aripiprazole. Kindly consult your doctor for examination.

Hope this helps.
Thanks.

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Brief Answer:
increased dose should show its effect in another two weeks.

Detailed Answer:
Aripiprazole has already started working for you. If you are having sedation with this, you can take it at night.

Meditation and pranayam are traditional yogic techniques which a yoga teacher can teach you exactly.

We recommend its practice since various researches have shown these techniques to be efficacious in mental health issues.

You can learn them from a nearby person trained in these techniques. Doing them correctly is very important.

Meditation and pranayama should be a part of lifestyle. These are supplementary treatments.

Take the increased dose of drug for atleast two and it should show its effects then.

Yes you can take energy supplements.

Hope this helps.

Thanks.

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Brief Answer:
body will take sometime to adjust.

Detailed Answer:
Dear XXXXXXX Hello again.

I hope you are taking aripiprazole.

First, I would suggest you to take sertraline at night. It can cause laziness and drowsiness.

Whenever we start a new exercise schedule, the body takes time to adapt. Initially you can reduce the intensity of yoga and pranayama. As your stamina builds, you can increase the duration and intensity.

Regarding meals, the dinner should be lightest and breakfast should be good.
As you are having stomach upset, kindly avoid fatty and spicy foods. Stomach upset can be due to sertraline.

Depression disturbs sleep-wake cycle which normalises as the depression resolves.
It is good to take 1 hour nap after lunch. No problem in that.

I would suggest you to set small and easy targets for your day. Try to accomplish those. This will motivate you to do further work.
Work according to time. Set your time limits.

This may sound awkward but you can sit in front of mirror and talk positive things to yourself. This will actually work.

Do take your drugs regularly.

Hope this helps.
Thanks.

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Brief Answer:
some mood fluctuations are normal.

Detailed Answer:
Hello Dear XXXXXXX

I am sorry that I am unable to understand what do you mean by "normal mood fluctuations are finished".
Does it mean that you are not able feel pleasure or sadness like a normal person?
Or does it mean that you have become emotionally numb and do not feel anything?

Kindly explain on these points.

Bipolar disorder has symptoms of depression alternating with symptoms of mania. In mania, there is elated mood, new interests, racing thoughts, decreased need for sleep, extravagant behaviour.
Have you ever had these kind of symptoms?

Some mood fluctuations are normal and every person experiences this.

You are having depression since 2007. This is a long duration. At present, it is difficult to say when you can stop the medicines completely. This depends on how your symptoms respond to treatment.

Aripirazole will take time.

Hope your doubts are cleared.
Kindly revert back with the details.

Thanks.

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