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Bupropion augment for anxiety?


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15 hours ago, Iceberg said:

I have always thought that summoning the required patience is one of the hardest parts of mental illness. Good luck with future improvement!

Thanks, @Iceberg! Appt went well this morning. Talking to him about the low-grade anxiety and irritability that has stuck around, his suggestion was to back the bupropion down to 150mg. But after some discussion, we decided to keep everything as it is for another month before we make any more changes.

Here's to patience...

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  • 2 weeks later...

So two weeks later, I'm not feeling too hopeful. I still feel "keyed up" a good portion of the time with low-grade anxiety and irritability. But no panic or rage/explosiveness. So everything is smoothed over but still above level.

I've been at 30mg of mirtazapine for 4 weeks and on 300mg of bupropion for 8 weeks. The low level tension doesn't seem to be getting better and I'm (literally) chewing my lips to hell. So I called into the pdoc, and I'm going to drop back down to 150mg of bupropion for the next two weeks until my appointment. Then decide if 150mg is both effective enough and tolerable enough, or if we need to swap it out for desvenlafaxine or duloxetine.

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On 3/29/2021 at 9:31 AM, browri said:

Whereas, when they did trials for aripiprazole as an augment to an antidepressant for major depressive disorder, there was considerably higher weight gain when compared to bipolar or schizophrenic cohorts that weren't taking antidepressants.

This is really helpful, thank you. My mom almost definitely would have been on it with an SSRI, but I will ask her. If I'm understanding right, you think that without an SSRI on board, the weight gain might not be such an issue on something like abilify? 

Sadly I had to pause bupropion for now. It was giving me really extreme obsessive thoughts and 2X daily panic attacks. My GP has finally, after years of asking, referred me to a psychiatrist who hopefully I'll be able to see regularly, rather than always going through the one at my doctor's office, who also refuses to think outside the box and listen to me. 

I'm considering that a low dose antipsychotic or mood stabilizer on its own, or maybe with bupropion again once my major anxiety triggers are a little bit more managed could be good. I just can't do an SSRI or SNRI ever again (mostly due to being put on them starting around age 13, and then throughout my entire teens and early twenties, and feeling traumatized by the way that affected sexual development, and....the unforgettable effexor withdrawals due to being a disorganized teen), and I want a pdoc who will respect that. So fingers crossed. 

Also curious about what the neuro-chemical difference between a mood stabilizer and an antipsychotic even is, if you have the energy to break that down for me? 

As always, thanks so much. 

I hope you're feeling well. ❤️ 

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On 4/20/2021 at 11:18 AM, browri said:

So two weeks later, I'm not feeling too hopeful. I still feel "keyed up" a good portion of the time with low-grade anxiety and irritability. But no panic or rage/explosiveness. So everything is smoothed over but still above level.

I've been at 30mg of mirtazapine for 4 weeks and on 300mg of bupropion for 8 weeks. The low level tension doesn't seem to be getting better and I'm (literally) chewing my lips to hell. So I called into the pdoc, and I'm going to drop back down to 150mg of bupropion for the next two weeks until my appointment. Then decide if 150mg is both effective enough and tolerable enough, or if we need to swap it out for desvenlafaxine or duloxetine.

Sorry just saw this part! I hope the 150 is working for you. I've always felt that it's a pretty decent dose, I think I've even lamented that there's no bupropion 100XL. But of course everyone is different. 

I'm super familiar with the wellbutrin chewing. Weirdly, it started for me when I was on the med in like, 2018, and I stopped because it was so bad - grinding my teeth in the daytime almost like a tic. Didn't really go away. Now it goes away when I'm ON wellbutrin and comes back when I'm off, which I can't figure out. Usually only flares up during extreme anxiety/stress, and I can mostly get it under control with breathing etc. 

I found buspirone completely useless for anxiety or anything to do with mood, but fwiw a low dose (I think 15mg/day) did cut the bruxism from wellbutrin. 

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46 minutes ago, Selkie said:

This is really helpful, thank you. My mom almost definitely would have been on it with an SSRI, but I will ask her. If I'm understanding right, you think that without an SSRI on board, the weight gain might not be such an issue on something like abilify?

Also curious about what the neuro-chemical difference between a mood stabilizer and an antipsychotic even is, if you have the energy to break that down for me?

❤️

To your first question about aripiprazole and weight, in order to understand whether or not it will make a difference, it's important to understand the why of it. For most people, aripiprazole, unlike other antipsychotics, doesn't have a significant direct impact on metabolic parameters like fasting blood glucose, lipids, prolactin, etc. Most of those side effects from other antipsychotics occur via dopaminergic antagonism, and in the case of olanzapine and clozapine particularly, cholinergic antagonism. However aripiprazole is a dopamine partial agonist with an intrinsic activity at these receptors greater than 50%. Oftentimes >60%. And aripiprazole's occupancy of dopamine receptors is significant. More dopamine activation than blockade may be why aripiprazole is unlikely to cause these symptoms via that system and also having little interaction with the cholinergic systems to begin with.

However, just because there is no metabolic dysfunction, doesn't mean that the patient can't gain weight. The hunger drive is controlled through a variety of hormones (e.g. glucagon, ghrelin), and serotonin acts as part of a feedback system to regulate our hunger drive. Broad activation of serotonin receptors by a simple SSRI can often lead to reduced appetite, nausea, vomiting, all negative gastrointestinal side effects but only due to the impact that increased serotonin levels have on feeling less hungry along with the fact that 80% or so of the body's serotonin supply is located in the gut. The 5HT2C receptor has been identified as an important receptor in that feedback loop. Activation makes you feel full. That's the science that lorcaserin is built on. Block that receptor and people describe inexplicably being unable to feel full and notably crave carbohydrates and sweets, in particular.

Aripiprazole has a fairly high affinity for the 5HT2C receptor, and it acts as a partial agonist at about 40-60%. So in the absence of significant levels of serotonin, it will act more as an agonist. However, when aripiprazole is administered with an SRI, baseline intrasynaptic serotonin levels are higher, making aripiprazole behave more as an antagonist. So with an SRI, you might actually feel more hungry on aripiprazole than if you took aripiprazole by itself. At least that's the theory behind the weight differences in trials.

As for the difference between mood stabilizers and antipsychotics, there are lots of opinions on how things should be named like neuroscience-based nomenclature that says we should do away with terms like mood stabilizer for lithium and antipsychotic for aripiprazole and start calling them by what they do. So aripiprazole might instead be called a serotonin-dopamine activity modulator (SDAM).

However, the classic, general rule is that the mood stabilizer category contains only one drug and that's lithium. Drugs like valproate, lamotrigine, carbamazepine are ultimately called anticonvulsants. One might call valproate an anti-manic agent, yet despite more emerging evidence that valproate might have ability to prevent bipolar depressive episodes there's still hesitation to actually call it a mood stabilizer because most medications don't have the sheer volume of evidence that lithium has.

Antipsychotic is almost invariably a term reserved for dopamine antagonists, whether they do or do not have serotonergic activity. However these are commonly used as mood stabilizers nowadays, and pdocs will often refer to them as mood stabilizers to try and move them away from the stigma associated with the word psychosis. There's also something to be said for the fact that if something is effective against more things than psychosis, then calling it an antipsychotic is kind of a narrow way of conceptualizing something.

41 minutes ago, Selkie said:

Sorry just saw this part! I hope the 150 is working for you. I've always felt that it's a pretty decent dose, I think I've even lamented that there's no bupropion 100XL. But of course everyone is different. 

Past few days have been okay. Agree with you that a 100mg XL would probably have a good market.

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  • 2 weeks later...

@Selkie 

So I had my pdoc appointment, and we decided to replace the Wellbutrin XL (bupropion) with Pristiq (desvenlafaxine). I brought up the low-grade irritability/anxiety from Wellbutrin again. His instinct was to shave off some of the irritability and anxiety with Risperdal (risperidone), which I was very open to, but I also pointed out to him that despite my improved motivation and drive on 300mg bupropion, that I still didn't feel in a very good mood, and even all the while I would be going about and doing the things I'm not motivated to do, my thoughts are just negative the whole time. I don't really feel that bupropion has really done a whole lot to address the WHOLE depression even with mirtazapine on-board.

With that in mind, he was more open to switching the bupropion because this is my third trial of it, and it has largely been similar to the other trials despite the different med cocktail "background". I told him I was still open to risperidone after this if I was still finding my thoughts are still agitated.

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  • 1 month later...

Hi @browri - I haven't logged on in a while, I was visiting my gf in the states and now we're quarantined in Canada. I actually have an appointment (remote) with a brand new pdoc tomorrow, which I am really optimistic about, he has a very good reputation and I'm really grateful to finally be able to talk to a psychiatrist directly, without going through my GP. 

How are you feeling after a month on pristiq? I've been on effexor before, years and years ago - do you find it to feel different from that one? 

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1 hour ago, Selkie said:

Hi @browri - I haven't logged on in a while, I was visiting my gf in the states and now we're quarantined in Canada. I actually have an appointment (remote) with a brand new pdoc tomorrow, which I am really optimistic about, he has a very good reputation and I'm really grateful to finally be able to talk to a psychiatrist directly, without going through my GP. 

How are you feeling after a month on pristiq? I've been on effexor before, years and years ago - do you find it to feel different from that one? 

So I did a "hard" switch from Wellbutrin 150mg to Pristiq 50mg. Started it on 5/4 with the Wellbutrin and the next day 5/5 stopped taking the Wellbutrin. Because of the Remeron on-board and switching from Wellbutrin to Pristiq I started experiencing some visual disturbances. Nothing too serious, but enough that I wanted to discontinue the Remeron, which I did on 5/10, and I pretty much just discontinued it right at 30mg. Didn't even bother titrating. I was having issues with attention/focus with work and everything. So we needed to act quickly but the visual disturbances weren't significant enough to warrant anything like hospitalization. By half-life, Wellbutrin probably cleared my system around 5/13 and Remeron around 5/20. However it probably wasn't until sometime this past week that I really started to feel better I think from the Pristiq. It's been since January that I've taken a serotonin reuptake inhibitor, and I'm now starting to realize what I lost by discontinuing an SSRI or SNRI.

So now I'm just taking Depakote ER, Pristiq, and Vyvanse. However, I do believe I'm going to take my pdoc up on his offer of low-dose Risperdal to help with sleep and deal with some break-through mixed stuff that I don't really like. Still, I had forgotten just how much I love Pristiq. We're very compatible. I've taken 50mg before and I've also taken 150mg Effexor XR when I had to switch off Pristiq due to an insurance change (this was back in 2013).

Generally speaking, 150mg venlafaxine hydrochloride will yield steady state plasma concentrations of O-desmethylvenlafaxine equivalent to those produced by 50mg of desvenlafaxine succinate. So they are supposedly "equivalent" doses. However, that isn't always the case for everyone. At 150mg=50mg they are generally equivalent in efficacy where desvenlafaxine is more tolerable. Desvenlafaxine can be dosed up to 400mg, but in trials, when the effect size was averaged out across all people in the study, doses greater than 50mg generally didn't make much of a difference and caused more side effects. So that means that while 150mg venlafaxine = 50mg desvenlafaxine, 300mg venlafaxine does not generally equal 100mg desvenlafaxine. 300mg of venlafaxine may produce O-desmethylvenlafaxine levels equivalent to 100mg desvenlafaxine, but while tolerability gets worse for both, efficacy is generally only better for venlafaxine at 300mg and equivalent efficacy is not seen from 100mg desvenlafaxine, even though they produce similar levels of O-desmethylvenlafaxine at steady state.

In essence, if 150mg of Effexor XR is sufficient for your depression but you have issues with side effects, Pristiq 50mg may definitely be for you. And if you switch and find that Pristiq 50mg is not quite enough oomph, you can try the 100mg, but you might have just been better off going to 225mg or 300mg on the Effexor at that rate because they'll be just as intolerable but far more effective.

Although, again, not everyone is the same, and this assumes you even have to go higher then 50mg on Pristiq. Currently and historically, I've personally found 50mg of Pristiq to be enough.

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