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I'm running out of antidepressants to take. I've been on Zoloft (3 times), Prozac, Effexor, Celexa, Lexapro, Remeron, Cymbalta, Wellbutrin, Buspar, Seroquel, Ablify, Zyprexa, and others (I also refuse to go on Paxil because of the horrible side effects which are similar to Effexor). I've been diagnosed with Major Depression and Anxiety Disorder with Panic Attacks. Zoloft was the first medicine I was put on 8 years ago and did wonders for me. I then took myself off of it and then I crashed into deep depression again. I've tried it another two times and never got the same response. The only medicine that has always worked for me consistantly is Xanax which I take on a as needed basis. Any suggestions for different meds?

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there are many here among us that have gotten on the good foot with an AC in place of an AD. new pdoc read me the riot act as re: xanax- his clinical experience has led him to have his patients drop the stuff. benzos and hypnotics drive depression. that's his take.

i am a week w/o minor tranqs but jigging up on a pair of meds. thus have no clear idea of where i am in this depression/bi-p wheel of fortune. Lamictal put me back on my game but because of side effects, i had to drop it. now that benzos/ sleepers are out of the mix, he's got me going back up again.

you dropped seroquel and i am titrating up on the stuff. gets me sleep and that's part and parcel of my problems.

best,

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If you've got insurance, rule out non-psychiatric causes. Find a good internist and get an assload of blood tests done, hormone levels in particular.

Also get a second opinion. Have you been seeing the same pdoc the whole time? Many meds can work synergisticly when used in combination with other meds, so the right right pairing could work where neither med did when taken individually.

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I would second r.mcmurphy's suggestion about an AC to see if that helped. Ask your pdoc about Lamictal. It works well for many people with depression - especially when it's combined with an antidepressant.

Maybe, like Velvet says, you need to start thinking about a combo of meds. Many, many people need more than one med to do the trick. The trick, obviously, is finding the right combo.

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I would second r.mcmurphy's suggestion about an AC to see if that helped. Ask your pdoc about Lamictal. It works well for many people with depression - especially when it's combined with an antidepressant.

Maybe, like Velvet says, you need to start thinking about a combo of meds. Many, many people need more than one med to do the trick. The trick, obviously, is finding the right combo.

I've had many blood tests at least 5 that I know of and showed nothing unordinary. I've been on many different combos, usually at least 2-3 different meds at one time. Also I've had 7 different psychitrists.

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Lithium, dosed to effect or a serum level (SL) between 0.8-1.0. Best evidence base.

Nortriptyline, dosed to the serum level between 100-150 ng/dL. If there's a hint of bipolarity, though, be cautious. And if that many meds have failed, there's a hint of bipolarity. So be cautious. Other TCAs, appropriately dosed, can work as well. Nortriptyline, however, has the SL monitoring, which is nice, and has a little more NE kick. Worth thinking about with your history with Zoloft.

Lamictal. Maybe a safer bet than nortrip if there's a hint of bipolarity. Not hardly an anxiolytic, though.

Augmentation with T3, especially if TSH is >2.0. Especially with lithium, too.

The other ones SZS listed, although I'm not a big Abilify or Geodon girl, personally. Evidence, yes, but they're augmentation drugs. I'd throw in a stronger vote for Zyprexa.

Did I mention lithium already?

Xanax is not an antidepressant, as you know, and won't do zip for the degeneration that occurs with a mood d/o. Good for you for continuing to pursue this.

Or there's lithium. Because everyone needs some neuronal regrowth after years of really crappy depression.

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Lithium, dosed to effect or a serum level (SL) between 0.8-1.0. Best evidence base.

Nortriptyline, dosed to the serum level between 100-150 ng/dL. If there's a hint of bipolarity, though, be cautious. And if that many meds have failed, there's a hint of bipolarity. So be cautious. Other TCAs, appropriately dosed, can work as well. Nortriptyline, however, has the SL monitoring, which is nice, and has a little more NE kick. Worth thinking about with your history with Zoloft.

Lamictal. Maybe a safer bet than nortrip if there's a hint of bipolarity. Not hardly an anxiolytic, though.

Augmentation with T3, especially if TSH is >2.0. Especially with lithium, too.

The other ones SZS listed, although I'm not a big Abilify or Geodon girl, personally. Evidence, yes, but they're augmentation drugs. I'd throw in a stronger vote for Zyprexa.

Did I mention lithium already?

Xanax is not an antidepressant, as you know, and won't do zip for the degeneration that occurs with a mood d/o. Good for you for continuing to pursue this.

Or there's lithium. Because everyone needs some neuronal regrowth after years of really crappy depression.

I tried Nortrip and had a bad response to it. I couldn't eat, sleep, and felt anxious all the time. But I might talk to my doctor about Lamictal or Lithium.

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Nortriptyline, dosed to the serum level between 100-150 ng/dL. If there's a hint of bipolarity, though, be cautious. And if that many meds have failed, there's a hint of bipolarity. So be cautious. Other TCAs, appropriately dosed, can work as well. Nortriptyline, however, has the SL monitoring, which is nice, and has a little more NE kick. Worth thinking about with your history with Zoloft.

You're kidding, right? Having to drop medications because they stop working so well or because of side effects does not indicate "bipolarity"

And the TCAs are a class of medications based on similar chemical structure, unlike SSRIs which are grouped by similar function. It's the one group of psych meds that requires a really good look at mechanism or action and distribution of actual side effects before swapping. For that matter, Nortriptyline is probably THE worst of the lot for someone diagnosed with GAD. Speed would leave most people feeling better.

*sigh* and T3, aside from being a thyroid hormone and not something to play with lightly, has a decent record as an augmenting medication only for some of the TCAs.

So far, all TCB has disclosed is having been on several AD combinations, of unknown dose ranges, and not being satisfied with whatever is being prescribed then or now, for some reason(s). Also, an unknown dose of Vivactil was too activating. Without knowing why Cymbalta and Wellbutrin are off the table for consideration, it's no good discussing noradrenergics with GAD as an official diagnosis.

TCB is also refusing Paxil because some idiot claimed the side effects were just like Effexor, even though the worst effects from Effexor are usually associated with sudden discontinuation, and the worst from Paxil are pretty much the same as for any serotonin reuptake inhibitor.

This is exactly why Jerod suggests keeping a log of what worked, what didn't, on what doses, and WHY it did/didn't work. Without more background, it's just not useful to say "Try this!" Just more wasted time spinning the med-go-round.

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The most important thing is to make sure you have the right dx. For example, depression and recurrent depression are two different beasts with recent neuroimaging indicating that in some cases the later may be a cousin of bipolar.

You tried one SSRI and it worked wonders. Then it didn't and neither did similar medications. Then you tried it again. That medication didn't change its chemical structure during that time. Something must have been different the later times around though. That something is you. You need to figure out what it is. While it's not uncommon for a medication to be less effective on subsiquent attempts, another in the same family should have helped.

Generally it doesn't make sense to try more than a few SSRIs before assuming that (just) serotonin reuptake inhibition isn't going to do it for you, btw. To keep trying more is a waste of time. Trying both lexapro and celexa makes even less sense, part of why I suggested a second opinion.

Also take a look at my summery of Stahl's "heroic combos" here:

[link=http://www.crazyboards.org/forums/index.php?showtopic=19361&st=2&p=259593&#entry259593" target="_blank]

http://www.crazyboards.org/forums/index.ph...mp;#entry259593

[/link]

Edit: Wonky linky. 00T

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Generally it doesn't make sense to try more than a few SSRIs before assuming that (just) serotonin reuptake inhibition isn't going to do it for you, btw. To keep trying more is a waste of time. Trying both lexapro and celexa makes even less sense, part of why I suggested a second opinion.

SSRI induced anxiety or hypo/mania or SSRI poop-out + panic attacks = good probability of BD.

Second opinion is a very good idea.

SZS

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The most important thing is to make sure you have the right dx. For example, depression and recurrent depression are two different beasts with recent neuroimaging that in some cases the later may be a cousin of bipolar.

You tried one SSRI and it worked wonders. Then it didn't and neither did similar medications. Then you tried it again. That medication didn't change its chemical structure during that time. Something must have been different the later times around though. That something is you. You need to figure out what it is. While it's not uncommon for a medication to be less effective on subsiquent attempts, another in the same family should have helped.

Generally it doesn't make sense to try more than a few SSRIs before assuming that (just) serotonin reuptake inhibition isn't going to do it for you, btw. To keep trying more is a waste of time. Trying both lexapro and celexa makes even less sense, part of why I suggested a second opinion.

Also take a look at my summery of Stahl's "heroic combos" here:

[link=http://www.crazyboards.org/forums/index.php?showtopic=19361&st=0&p=259593&#entry259593" target="_blank]http://www.crazyboards.org/forums/index.ph...mp;#entry259593[/link]

I have been diagnosed with recurrent major depression. But nothing really has changed for me. I don't have mood swings where I feel good and then suddenly crash if I were to have bipolar disorder. I constantly feel down all the time. And as for second opinions I have had 7 different opinions and been hospitlized twice.

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I have been diagnosed with recurrent major depression. But nothing really has changed for me. I don't have mood swings where I feel good and then suddenly crash if I were to have bipolar disorder. I constantly feel down all the time. And as for second opinions I have had 7 different opinions and been hospitlized twice.

TCB-

Bipolar disorder doesn't always mean 'feel good'. In fact agitation/anxiety issues are more common than 'feel good' issues.

I still think another opinion wouldn't hurt.

SZS

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I have been diagnosed with recurrent major depression. But nothing really has changed for me. I don't have mood swings where I feel good and then suddenly crash if I were to have bipolar disorder. I constantly feel down all the time. And as for second opinions I have had 7 different opinions and been hospitlized twice.

TCB-

Bipolar disorder doesn't always mean 'feel good'. In fact agitation/anxiety issues are more common than 'feel good' issues.

I still think another opinion wouldn't hurt.

SZS

Really? I do experience a good amount of agitation/anxiety. I'll keep that in mind when I see my doctor next.

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You're kidding, right? Having to drop medications because they stop working so well or because of side effects does not indicate "bipolarity"

Yes. I'm well aware. Hence the use of the figure of speech 'hint of bipolarity' to suggest this concept: "Given some elements of your history, perhaps you should discuss the concept of a diagnostic re-evaluation with your clinician. There is some overlap between what is termed 'treatment resistant depression' - which you may or may not suffer from - and the concept of bipolar disorders."

However, I will endeavor to be more precise in future.

Stopping due to side effects/ADRs - caveat: depending on the ADR - is not associated with diagnosis of BPAD down the road. Repeated failure of ADs is a soft sign that merits ears up and a closer look.

I hate diagnostic creep as much as the next person. BPAD is simultaneously over- and under-diagnosed to an extraordinary degree. On the other hand, there's a reason Goodwin and Jamison's text is subtitled the way it is. But that's a major concept discussion we should maybe move elsewhere.

Recurrence, and recurrence, and recurrence yet again is the shared issue here. I see VE already addressed that.

And the TCAs are a class of medications based on similar chemical structure, unlike SSRIs which are grouped by similar function. It's the one group of psych meds that requires a really good look at mechanism or action and distribution of actual side effects before swapping. For that matter, Nortriptyline is probably THE worst of the lot for someone diagnosed with GAD.

Nortriptyline can be activating, yes. It's also been used to treat comorbid severe depression and GAD, successfully. (The worst of the lot in anxiety is -IMO- protriptyline, which indeed wasn't tolerated.) Once the depressive sx alleviate, the GAD might reduce significantly.

*sigh* and T3, aside from being a thyroid hormone and not something to play with lightly, has a decent record as an augmenting medication only for some of the TCAs.

You're right. It has a downright crappy record in MDD, and mainly as an accelerator of response.

And it's important if not vital to monitor TFTs while using it. Very rarely done.

None of these drugs should be played with lightly.

This is exactly why Jerod suggests keeping a log of what worked, what didn't, on what doses, and WHY it did/didn't work. Without more background, it's just not useful to say "Try this!" Just more wasted time spinning the med-go-round.

Yes. What is called a "chart" is a good place to start.

My intent in commenting was for TCB to be able to go research more options on her/his own and then engage in thoughtful discussion with his or her pdoc. I find that I and most people are able to do that research most productively if there are some areas of focus initially.

Your points are well taken and appreciated.

Silver

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I have been diagnosed with recurrent major depression. But nothing really has changed for me. I don't have mood swings where I feel good and then suddenly crash if I were to have bipolar disorder. I constantly feel down all the time. And as for second opinions I have had 7 different opinions and been hospitlized twice.

TCB-

Bipolar disorder doesn't always mean 'feel good'. In fact agitation/anxiety issues are more common than 'feel good' issues.

I still think another opinion wouldn't hurt.

SZS

Really? I do experience a good amount of agitation/anxiety. I'll keep that in mind when I see my doctor next.

More often my "elevated" periods are agitation, anxiety and irritability than feeling good or grandiose.

And I suffer from depression far more often than elevated states.

FWIW...

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Nortriptyline, dosed to the serum level between 100-150 ng/dL. If there's a hint of bipolarity, though, be cautious. And if that many meds have failed, there's a hint of bipolarity. So be cautious. Other TCAs, appropriately dosed, can work as well. Nortriptyline, however, has the SL monitoring, which is nice, and has a little more NE kick. Worth thinking about with your history with Zoloft.

You're kidding, right? Having to drop medications because they stop working so well or because of side effects does not indicate "bipolarity"

And the TCAs are a class of medications based on similar chemical structure, unlike SSRIs which are grouped by similar function. It's the one group of psych meds that requires a really good look at mechanism or action and distribution of actual side effects before swapping. For that matter, Nortriptyline is probably THE worst of the lot for someone diagnosed with GAD. Speed would leave most people feeling better.

*sigh* and T3, aside from being a thyroid hormone and not something to play with lightly, has a decent record as an augmenting medication only for some of the TCAs.

So far, all TCB has disclosed is having been on several AD combinations, of unknown dose ranges, and not being satisfied with whatever is being prescribed then or now, for some reason(s). Also, an unknown dose of Vivactil was too activating. Without knowing why Cymbalta and Wellbutrin are off the table for consideration, it's no good discussing noradrenergics with GAD as an official diagnosis.

TCB is also refusing Paxil because some idiot claimed the side effects were just like Effexor, even though the worst effects from Effexor are usually associated with sudden discontinuation, and the worst from Paxil are pretty much the same as for any serotonin reuptake inhibitor.

This is exactly why Jerod suggests keeping a log of what worked, what didn't, on what doses, and WHY it did/didn't work. Without more background, it's just not useful to say "Try this!" Just more wasted time spinning the med-go-round.

With all due respect Null0Trooper, Silver knows what she is talking about. Failing a number of ADs is a sign of potential bipolar, and I believe that's all that was said. Similarly, anxiety and agitation can be symptoms of Bipolar II. Doesn't mean they are enough for a dx, it just means they are some of the sign posts, especially when mixed with Major Depression as TCB stated he also had.

As for T3, it has some success beyond tricyclics. [link=http://ajp.psychiatryonline.org/cgi/content/full/163/9/1519" target="_blank]http://ajp.psychiatryonline.org/cgi/content/full/163/9/1519[/link]

A Comparison of Lithium and T3 Augmentation Following Two Failed Medication Treatments for Depression: A STAR*D Report

OBJECTIVE: More than 40% of patients with major depressive disorderdo not achieve remission even after two optimally deliveredtrials of antidepressant medications. This study compared theeffectiveness of lithium versus triiodothyronine (T3) augmentationas a third-step treatment for patients with major depressivedisorder. METHOD: A total of 142 adult outpatients with nonpsychoticmajor depressive disorder who had not achieved remission orwho were intolerant to an initial prospective treatment withcitalopram and a second switch or augmentation trial were randomlyassigned to augmentation with lithium (up to 900 mg/day; N=69)or with T3 (up to 50

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With all due respect Null0Trooper, Silver knows what she is talking about. Failing a number of ADs is a sign of potential bipolar, and I believe that's all that was said. Similarly, anxiety and agitation can be symptoms of Bipolar II. Doesn't mean they are enough for a dx, it just means they are some of the sign posts, especially when mixed with Major Depression as TCB stated he also had.

It could also be a sign of potential seasonal affective disorder, potential hormone imbalance, or potentially being a can of spam. ADs don't do much for spam. In reality, failing a number of ADs is in and of itself indicative of nothing other than potential !depression. In short, it's indicative of misdiagnosis. A lot more information is required to determine what it is after that, and we've not been made privy to such.

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Are you sure ADs don't do much for Spam?

Disturbingly, a quickie Medline search for [antidepressant ham] brought up 742 results. Then I realized (duh) they were catching HAM-D. For a moment there...

I'll assume this is based on experience, then. ;)

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Any suggestions for different meds?

You could try Risperdal for the panic/anxiety.. it helps with mine. Other than that.. Lithium and Lamictal would be meds to try since you didn't list them. The best bet would be to pick an AD that did something; even if it's just a little - and augment it with either something new or another med that did a little bit of something else. It's more about finding something that works than determining exactly where you are on the mood spectrum, IMO.

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