Cocktail help please?

[Ophelia12]

Current cocktail:

Nortriptyline 25mg (for depression and IBS symptoms)

Trazodone 50 mg (for insomnia)

Xanax 0.25 3 times daily prn

I'm looking for suggestions on changing my cocktail to make it more effective. I have Depression, GAD, and OCD. I've had problems with depression for about 15 years, was in remission for a while, and starting having problems again having my son.

The Nortriptyline only works about, say, 70% on my depression, but I don't want to switch to another drug because it completely rids me of IBS symptoms. Same thing with anxiety, it helps, but not as much as I would like. I do take Xanax, as needed, but my doctor doesn't want me on it long-term, and honestly, I'd rather be on a maintenace medicine for it that would help prevent it so I wouldn't need to the Xanax anymore. The Trazodone is obviously for insomnia.

Past Meds

SSRI's: Citalopram made me deathly sick and I was never able to titrate above 10 mg/day. Zoloft was okay, but it aggravated my IBS symptoms and made my insomnia pretty bad.

Remeron: It worked great, but it just made me too sleepy to the point of not being functional during the day. I tried the 15 and 30 mg.

Buspar: Didn't really do much for me.

Those are just the ones I've tried in the past year. I know I tried a bunch of SSRI's when I was a teenager and always had problems with nausea, but I can't which ones they were unfortunately.

[tryp]

You could consider adding an atypical antipsychotic. Seroquel would help with both depression and anxiety, though it can be fairly sedating. There are other AAPs that might also be options.

Also are you at the max dose for the nortriptyline? What does your doctor say?

[jt07]

I'm a big fan of Abilify simply because it works so well for me. It may or may not work as well for you, and some people have trouble with it (it's a drug that people either love or hate with little grey area) but it is something to talk over with your doctor. It may be somewhat problematic for you because you suffer from anxiety, and Abilify greatly aggravated my anxiety at low doses. But when I got to 10 mg, wow! What a difference! YMMV

[momo77]

in my opinion you should only take anti-psychotics if your bipolar....or schizo....if you are not that then DO NOT TAKE IT its not worth it, you end up feeling like a zombie and t actually shrinks your brain...atleast your just dealing with anxiety and depression like me....we can beat this , you add antipsychotics into the mix and when you try to withdraw from them you ended up WAY worse possibly triggering anything from mania to psychosis to paranoia....then your doc tells you you have a new diagnosis and your schizo or bipolar and that you gotta be on drugs for the rest of your life and your fucked.....fuck that trust me you dont want it

[jt07]

in my opinion you should only take anti-psychotics if your bipolar....or schizo....if you are not that then DO NOT TAKE IT its not worth it, you end up feeling like a zombie and t actually shrinks your brain...atleast your just dealing with anxiety and depression like me....we can beat this , you add antipsychotics into the mix and when you try to withdraw from them you ended up WAY worse possibly triggering anything from mania to psychosis to paranoia....then your doc tells you you have a new diagnosis and your schizo or bipolar and that you gotta be on drugs for the rest of your life and your fucked.....fuck that trust me you dont want it

Do you have any science to back any of this up?

[Guest Vapourware]

in my opinion you should only take anti-psychotics if your bipolar....or schizo....if you are not that then DO NOT TAKE IT its not worth it, you end up feeling like a zombie and t actually shrinks your brain...atleast your just dealing with anxiety and depression like me....we can beat this , you add antipsychotics into the mix and when you try to withdraw from them you ended up WAY worse possibly triggering anything from mania to psychosis to paranoia....then your doc tells you you have a new diagnosis and your schizo or bipolar and that you gotta be on drugs for the rest of your life and your fucked.....fuck that trust me you dont want it

That's paranoid nonsense. Most reports show that medication actually prevents brain shrinkage and even promote regrowth.

[llama44]

I am not supporting the "momo" troll, but I do think that for regular depression and anxiety an AAP is overkill when so few AD's have been tried and the AD the OP is currently on is partially working. An increase in the dosage may be all that is needed. Drugs.com says that 25mg to 150mg per day is a normal adult dosage. The OP is on the lowest possible dosage of the medication.

[tryp]

Personally I sort of disagree with the notion that a reasonable dose of just about any drug can be automatically "overkill". I think that if my doctor had not had that philosophy and kept putting me on SSRI after SSRI when what I really needed was Lamictal, I probably would have been spared at least a year of depression.

But yes, the nortriptyline is still low and it's worth looking into raising it before upsetting the apple cart with a whole new med IMO - that's what I would consider, personally, anyway.

Ed. Okay, so maybe SOME treatments can be overkill right off the bat, but Seroquel was one of my first meds and in terms of side effects it's been one of the least bothersome medications I've tried (second only to Lamictal) and one of the most effective.

[llama44]

I never said that a reasonable dose of just about any drug is overkill. I said in this particular situation only in which the OP is on an AD that is working 70% she should consider an increase in the effective med rather than adding an AAP which may give more unwanted side effects and as you said, upset the apple cart. I did not say that adding an AAP to anyone's cocktail is overkill. Read my post again.

[jt07]

Actually, Abilify is approved for adjunct treatment in cases where an AD is partially working. If I did not try Abilify, I would have never known how "normal" felt because it's been so long that I'd forgotten. I certainly do not agree with anything that momo77 posted. Abilify has been a miracle med for me. Of course, that doesn't mean that it would be the same for the OP.

[Ophelia12]

You could consider adding an atypical antipsychotic. Seroquel would help with both depression and anxiety, though it can be fairly sedating. There are other AAPs that might also be options.

Also are you at the max dose for the nortriptyline? What does your doctor say?

No, I'm only taking 25 mg. She wants to me up to 50 mg currently. I tend to be sensitive to side effects, so she always starts me out really low on the scale. She is just my pcp though, and she would rather me speak to a pdoc if I'm interested in augmenting with an APP.

[Guest]

I know you said you didn't want to change any of what you're on but you may want to consider changing from nortriptyline to amitriptyline if the increase in nortriptyline to 50mg doesn't do the job for you. Nortriptyline is one of the active metabolites of amitriptyline. So, if nortriptyline doesn't do it for you then amitriptyline may. It's sort of like using a gun or a cannon (I know bad analogy but it's all I can come up with right now). If you're shooting at an elephant, you may want the cannon rather than the gun.

I tried nortriptyline and it didn't work nearly as well as amitriptyline. I completely understand not wanting to get off of your TCA. I take it for depression but helps with my IBS symptoms, pain from fibromyalgia, and pain I have from another med I must take. If someone told me I could only keep one of the meds I was on, I'd be keeping amitriptyline.

Luvox is good for OCD. It is an SSRI but its one of the first. It comes in a generic so it's dirt cheap. It is the only SSRI that I've ever been able to take. I know you can take it at the same time as you talk amitriptyline because I've done it and so has my daughter. Luvox stopped the counting that I do as part of my OCD. I didn't think anything would be able to stop that. Luvox is the only med I've ever taken that stopped that aspect of my OCD.

The folks that say don't use an atypical antipsychotic for depression need to do some more reading on the topic. AAPs are being used fairly routinely to augment medication cocktails for people with treatment resistant depression.

[llama44]

Exactly. Use an AAP for treatment resistant depression. She has tried only four meds (not including her current ones). Also her med is working at 70%. Does this sound treatment resistant? I don't think so.

I said over and over again that in this particular case. Not in every one with depression. AAP's have helped tons with depression. I know that. Don't say that I don't when you aren't sure. And I know you are referring to me so don't come back with "I wasn't talking about you!" I encourage you to read my posts again.

[Guest]

Exactly. Use an AAP for treatment resistant depression. She has tried only four meds (not including her current ones). Also her med is working at 70%. Does this sound treatment resistant? I don't think so.

I said over and over again that in this particular case. Not in every one with depression. AAP's have helped tons with depression. I know that. Don't say that I don't when you aren't sure. And I know you are referring to me so don't come back with "I wasn't talking about you!" I encourage you to read my posts again.

Maybe you need glasses. Go back and read the first post in this thread. The OP has tried four meds this YEAR.

I looked up the definition of treatment resistant depression. According to pubmed, TRD refers to inadequate response to at least one AD of adequate dose and duration. So it appears that the OP does indeed have TRD. If you have problems with this definition take it up with the folks at pubmed.

Oh and for the record, I wasn't talking about you. Contrary to what you may believe, not every thing I say has anything to do with you. Your paranoia is showing.

[midnightman]

If I could make one suggestion, I'd say try to get onto a longer-lasting benzo. Alprazolam / xanax is very short acting and may exacerbate your OCD when the dose begins to wear off, aka rebound anxiety. Clonazepam and Diazepam are two alternatives with longer half-lives that may be more "stabilizing" than alprazolam is. I know Clonazepam is actually approved as a mood-stabilizer in the US, at least, and I think it's the only benzo that is.

Edit - Another reason I'd suggest these benzos is that they tend to be easier to taper off of than the shorter acting ones, which may be especially beneficial if you and your doc don't plan on them being part of a daily treatment plan for an extended period of time to come.

Besides that, I would try working with what's already helping if I were you. As others have said, pushing the dose of the Nortriptyline may be helpful, so perhaps give that a shot? You could also increase the trazodone dose to 100mg if you wanted to try it as long as it didn't leave you feeling "hungover" in the morning. Even at a fairly low dosage, it still could affect your mood during the day with daily use.

I'd advise being cautious about AAP's but don't think you should rule them out. If anything, I'd say to try to work with what you're currently on (in terms of classes of medications) before adding a whole different entity to the mix if you don't feel it's really necessary. If dose changes of your current meds or changes made within a certain class of meds you're currently on doesn't help, then I'd start to look at things like mood stabilizers and AAP's with my pdoc.

This, however, is just what I PERSONALLY would do. In the end, it's your treatment, and only you and your pdoc can know what's best from personal experience.