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On 3/12/2018 at 12:33 AM, HydroCat said:

(First post... Hi etc.)

Effexor 225 - Depression & anxiety

Abilify 5 - OCD & tics

Ritalin 30 - ADHD

I have an “almost there” feeling, maybe a minor adjustment (or time?) will do.

Various degrees of failure: Cymbalta (worked but killed sex drive), Prozac, Zoloft, Wellbutrin, Milnacipran (WAY too activating), Trintellix (placebo, as far as I can tell), Risperdal (worked but was too sedating).

Welcome @HydroCat It seems we are on similar combos. How long have you been on this combo and have you had much noticeable benefit?

I am considering increasing my Effexor (currently at 150mg), as it seems it's helping stabilize me (as far as depression and anxiety) and Ritalin is helpful in the energy/focus area (Are you on Extended or Instant Release doses??). I am frustrated at the sexual dysfunction side effects (I get this from every A/D and SNRI it seems). I was debating on going back to Cymbalta, but I don't know. Trintillex was also like taking a placebo for me!

I really was hoping to feel more pleasure and "mood brightening" effects (something that prevents depression, but does not cut the "happy" feelings), but maybe that is just asking for too much!

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I have been on Cymbalta 90 and Abilify 5 for about 2 years, then anxiety levels started rising a bit, so my pdoc changed Cymbalta for Effexor XR.
150 was too low for me depression-wise, I noticed a significant improvement on 225, which should be equal to 90 Cymbalta. Makes sense.

Now my pdoc and I think that maybe the Abilify combo was causing the sexual side-effects, as I've been better long time ago on SSRI+Risperidone.
Tried going back on Risperidone but it made waking up for work an impossible mission, every morning.

Currently tapering off Abilify and will probably start with something else non-AP. Maybe Lamictal. Recent research found it useful for OCD.

I remember the "normal" and "quite" feeling well. It is there somewhere. Don't give up trying to find it.

About Trintellix, it gave me a somewhat weird feeling as though it is doing something, but that thing was not an AD. YMMV and all that.

Edited by HydroCat

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This stupid EKG is going to be a problem. I figured out where to go to get it done (apparently I can just walk into the local hospital's cardiology department with the requisition form from my doctor, no prior appointment necessary), but apparently the insurer-quoted $26–$95 price is an inaccurate estimate as when I contacted the local hospital to try to confirm what kind of price range I was looking at, I was informed that they bill my particular health insurer $234 for an EKG (in comparison, uninsured people are apparently billed $422), and they could not tell me how much of that billed amount my insurer would accept/reject (not even a ballpark figure). Then I dug up some old insurance claims from 2016 that had two previous EKGs on them (same health insurer, one EKG was done at the local inpatient psychiatric hospital as a screening EKG prior to initiating a trial of ziprasidone, the other was done at the local hospital's ER when I was in there after I attempted to kill myself by overdosing on my meds) and discovered that the accepted and paid-out total amount for each of them was approximately ~$320. Then I checked the Medicare Physician Fee Schedule and found out that they pay out <$20 for an EKG. Checking third-party national sources gave a wide range of price estimates. Alarmed at the massive disparities/variation I was seeing I tried contacting my health insurer to see if they could clarify things a little bit, and was told that they could give me no information whatsoever beyond the fact that apparently their own healthcare procedure cost estimate calculator's estimates should apparently not be considered to be reliable or anywhere near accurate.

Sooo basically I'm looking at anywhere from $26–$234 to get this EKG done, assuming that I can trust that the hospital actually quoted me the price for either the CPT code 93000 or the CPT codes 93005+93010 (and not something weaselly like just quoting 93005). The insurer's healthcare procedure cost estimate calculator spat out $26–$95 for CPT code 93000 in my area on my current plan with my deductible unmet (although perhaps the calculator is erroneously calculating the cost as what it would be if my deductible was met despite claiming to take that into account? that would mostly explain the observed price disparities... hmm...). Both previous insurer-billed EKGs were 93005+93010 combos (with ~$320 being the total combined amount paid out to the hospital per instance — back in 2016 the local ER had originally tried billing $398 for 93005 and $172 for 93010 before the insurer adjusted the price downwards on both of those).

I think I'm going to try to just go get it over with tomorrow morning and try to avoid worrying about the price any more until the bill turns up, since there's not exactly much I can do about the cost right now (I already checked to see if I have alternative options — but there were essentially no other viable options in my local area that are in-network) and I have to get this done irregardless of the cost anyways. I was tempted to just go today, but since this is only my first day back on the full dose I thought it'd probably be better to wait a day or two before getting it done to let things stabilize first...

On 4/20/2018 at 5:10 AM, Blahblah said:

@JustNuts Thanks for the info. I'm trying to decide what to do. I do have room to go up on Effexor, but part of me wonders if I should switch to Cymbalta (which has more NE and longer half-life). I was on that like 10 years ago, so don't really remember if it was much better. I guess Effexor is helping, I feel pretty stable and haven't had long dips in depression (I used to get triggered and then get stuck for days). Now depressive episodes are incredibly short, however, I'm stuck in the blahs (I wonder if Lamictal could be contributing to this???) Effexor Side effects are tolerable (typical dry mouth/throat clearing, constipation, a bit of "spaciness")

My main thing is that meds have helped prevent/stave off the worst depressive episodes, but I guess I always feel blah. Like it's good that my negative emotions aren't intense, but I can't remember the last time I felt pleasure or excitement in anything!! Every single one effects my sex drive (no orgasms either). But if I go off, I know I will be de-stabilized and experience alot of emotional lability (which includes more downswings). So it is a constant trade-off :-(

I tried Trintillex also, and I felt no effect whatsoever. I would be eager to try Fetzima, but the cost is a barrier/annoyance. So with less Serotonin (and more NE) does this mean it has less of a calming/blunting effect and more of increased heartrate, energizing, "fight or flight" restless legs, sort of effects? My physical energy level is fine. Since I'm on Ritalin, I don't want to get on something that has significant cardiovascular effects.

The lamotrigine could be contributing to the apathy. But it could just be inherent as well. It's rather hard to tell them apart with long-term depression, multiple comorbidities, and polypharmacy...

I'd say that's a decent description of what Fetzima is like. It's definitely somewhat additive with stimulants in its effects, although unlike bupropion there's no CYP2D6 enzyme inhibition to worry about, and in my experience it's not as troublesome as bupropion when it comes to increased HR/BP, increased anxiety, or a few other side effects (but then again I may just not tolerate bupropion well to begin with — not really sure).

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On 4/24/2018 at 8:54 PM, JustNuts said:

The lamotrigine could be contributing to the apathy. But it could just be inherent as well. It's rather hard to tell them apart with long-term depression, multiple comorbidities, and polypharmacy...

^^ Yes this is the thing! ^^  It's really tough when you have long term depression and tried so many different combos...How do you even know which meds are doing what (if anything) and of course, meds can possibly "poop out" so all you can do is after a long trial that isn't working, try to do a taper/wash out and after a break start something else? I don't know.

Then of course, if you go off any longterm med, you must expect some discontinuation symptoms for weeks (often longer). I hate how pdocs always attribute these discontinuation syndromes to "your disease symptoms coming back." All I know is my depression does not include physical aches, pains, migraines and flu-like symptoms, nausea, brain shocks, dizziness, etc - so I know in fact that discontinuation is indeed a thing and not just your "depression" coming back...I don't understand why doctors always deny this.

I'm just so sick of feeling stuck. I forgot what it's like to feel genuinely happy and it sure is tough to remain longterm on med combos when you don't feel they are greatly helping you feel much "better" - you just feel more blah if not numbed of strong emotions.

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Went in and got the EKG done today. In theory interpretation should be completed and the final report delivered to my psych within 24 hours, but it may be a bit longer. I should have access to the report through their online portal at that point, which is nice, assuming it works... I got to take a brief look at the EKG readout after it was printed, nothing was obviously abnormal outside of the 110 BPM HR (although the only specific measure that I could really interpret was the QTc value, which appeared to be within the normal range — I'm nowhere near qualified to interpret the rest of the EKG without access to references). In hindsight I regret not asking to take a quick picture of the printout before I left — I doubt I'll see the actual printout again and it was rather interesting (not to mention that it cost god knows how much money so I might as well get my money's worth out of it). Ah well, hindsight is 20:20.

4 hours ago, Blahblah said:

^^ Yes this is the thing! ^^  It's really tough when you have long term depression and tried so many different combos...How do you even know which meds are doing what (if anything) and of course, meds can possibly "poop out" so all you can do is after a long trial that isn't working, try to do a taper/wash out and after a break start something else? I don't know.

Then of course, if you go off any longterm med, you must expect some discontinuation symptoms for weeks (often longer). I hate how pdocs always attribute these discontinuation syndromes to "your disease symptoms coming back." All I know is my depression does not include physical aches, pains, migraines and flu-like symptoms, nausea, brain shocks, dizziness, etc - so I know in fact that discontinuation is indeed a thing and not just your "depression" coming back...I don't understand why doctors always deny this.

I'm just so sick of feeling stuck. I forgot what it's like to feel genuinely happy and it sure is tough to remain longterm on med combos when you don't feel they are greatly helping you feel much "better" - you just feel more blah if not numbed of strong emotions.

Yep. The eternal struggle. Good documentation and research can only help so much... And this is all incredibly cost and time intensive. Not to mention the lovely stigma. Such fun /s.

Attributing actual discontinuation symptoms to depression recurrence? That's odd. They shouldn't be trying to pull that BS.

I agree. I wish I had something more encouraging to say...but after four years, >60 medications, ~7 inpatient stays (with a total of ~5 months spent inpatient), 6 therapists (4 primary), 8 psychiatrists (4–5 primary), and ~$300,000 of healthcare bills during this period (out of pocket share was roughly ~$40k including all copays and premiums), well, I'm a bit overly jaded at this point. Am I better off than when I started? Indisputably. Am I satisfied with the ultimate outcome? Only somewhat. Am I happy? Not really, although at this point I do have a pretty good understanding of where a relatively considerable amount of my remaining dissatisfaction is coming from (unfortunately it's mostly not something I can fix easily or quickly, and although I can slowly work towards a resolution, it's unclear how well that'll work out or how long it'll take). The only advice I have is that well-informed strong self-advocacy is very important, you need to remain open to trying different things whenever it's practical to do so, and no matter how many setbacks you encounter (big or small), you have to keep moving forwards with your best effort or else you'll never improve.

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@JustNuts  Now that you got the EKG, will they change anything to your meds? Do they think that the stimulant causes the most cardiac effects? Or your combo in general? I'd like to get a solid baseline cardiac check also. Is an EKG is enough to really tell that everything is A-OK? Sometimes I notice in bed, my heart will go into a weird tachardia for a short bit and then slow down or skip beats. My mom had a heart issue (that was undiagnosed) and had a heart attack at age 58 (fairly young as she was in good health, but smoked during her life).

Yeah, there seems to be a fine line between med discontinuation symptoms and reoccurance of depression/illness. I consider the physical symptoms withdrawal, but I've also become severely depressed, uncontrollable crying, anxiety and fatigue issues right after stopping meds (but eventually those symptoms return to a baseline, and I remain stable for maybe 1-2 years medfree until the next "big" situational life trigger).

Since you have tried more meds than me - How/when do you decide when to stop a med or combo, take a break and start fresh with something new? Or switch out 1 med from your combo?? I usually stop a med if after 4-6 weeks, I still have intolerable side effects or worsening of symptoms, but there are some meds (like Effexor, Lamictal) that I've been on for over a year and I still feel depressed, negative with ruminations, and experience depression dives every 3 weeks. I guess I always start to question the efficacy long-term (in MY case personally). Meds are not improving my dysthymia at all and I wonder if they might be making it worse?

Is it true, according to research and drug studies, that meds are only tested on human subjects for a period of 6 months or so? And the results/efficacy reports are based solely on these short-term studies (with alot of post-marketing reports and bad side effects omitted?) I often worry that doctors have no idea what the longterm effects of meds are. I am pro-med, and I believe they are indeed effective in serious episodes and preventing worsening of diagnosis, suicidality. But there seems to be little evidence that staying on meds for life (when you have mainly chronic low-mid level depression or dysthymia) in all cases, increases quality of life....Something I always ponder (whether to go back to just taking meds only on a severe/major episodic basis & during winter months instead, etc) as when psych meds were first introduced, I think the idea was that they were for episodic/short term use (in most cases).

Edited by Blahblah

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Hello, this is my first post (nice to meet you and all),

 

Trazodone 100mg for depression (I was up to 150 but started getting a rash on my tongue)

Clonazepam drops (Rivotril) for anxiety, 3 in the morning, 8 before sleeping, that would make 1.1mg

Abilify 5mg (to help the trazodone)

 

I was on Wellbutrin XL 150 mg but got a rash on my tongue and body, Lamictal for some time until my lips swelled up like a real housewife of wherever

I used to take trileptal 300mg years ago for what my old psychiatrist told me was a "mild bipolarity", which is something I've never quite understood, but had been off meds for years. Then in November I had a bit of a breakdown and started on the wellbutrin. On saturday I had another breakdown, took some clonazepam to calm down until my pdoc could see me and now he's started me on abilify.

Right now I feel completely exhausted and can barely get out of bed and terrified because of the weight gain (it's always contributed heavily to my depression). I see some of you take metformin. How's that working for you?

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I just finished an exhausting ~10 hour work day on approximately 3 hours of sleep (oops), so bear with me here, this response might be a little incoherent despite the (currently quickly wearing off as I type this) caffeine & Adderall (I work in software development and am currently solely focused on a major cleanup/overhaul of the bloated and messed up codebase for the company's main product with a broad scope of action and not much support from the rest of the team (and while our >50k SLOC is still technically a "small" project in the big picture of things, it's still nowhere near a simple one, it's absolutely massive compared to codebases I've worked on in the past, it has very significant technical debt, there's extremely poor/minimal documentation available, it has been maintained haphazardly for years, it's fragmented to the point that the core devs & our team leader/director don't have enough knowledge to answer many important questions, and it's primarily written in C# (which is one of the software languages that I'm less comfortable with and have less experience with)), which is all rather mentally exhausting, especially so when I get too little sleep). So please tell me if I missed anything important or didn't answer anything in enough detail — hopefully my writing isn't too disjointed and/or riddled with errors to comprehend.

14 hours ago, Blahblah said:

@JustNuts  Now that you got the EKG, will they change anything to your meds? Do they think that the stimulant causes the most cardiac effects? Or your combo in general? I'd like to get a solid baseline cardiac check also. Is an EKG is enough to really tell that everything is A-OK? Sometimes I notice in bed, my heart will go into a weird tachardia for a short bit and then slow down or skip beats. My mom had a heart issue (that was undiagnosed) and had a heart attack at age 58 (fairly young as she was in good health, but smoked during her life).

Yeah, there seems to be a fine line between med discontinuation symptoms and reoccurance of depression/illness. I consider the physical symptoms withdrawal, but I've also become severely depressed, uncontrollable crying, anxiety and fatigue issues right after stopping meds (but eventually those symptoms return to a baseline, and I remain stable for maybe 1-2 years medfree until the next "big" situational life trigger).

Since you have tried more meds than me - How/when do you decide when to stop a med or combo, take a break and start fresh with something new? Or switch out 1 med from your combo?? I usually stop a med if after 4-6 weeks, I still have intolerable side effects or worsening of symptoms, but there are some meds (like Effexor, Lamictal) that I've been on for over a year and I still feel depressed, negative with ruminations, and experience depression dives every 3 weeks. I guess I always start to question the efficacy long-term (in MY case personally). Meds are not improving my dysthymia at all and I wonder if they might be making it worse?

Is it true, according to research and drug studies, that meds are only tested on human subjects for a period of 6 months or so? And the results/efficacy reports are based solely on these short-term studies (with alot of post-marketing reports and bad side effects omitted?) I often worry that doctors have no idea what the longterm effects of meds are. I am pro-med, and I believe they are indeed effective in serious episodes and preventing worsening of diagnosis, suicidality. But there seems to be little evidence that staying on meds for life (when you have mainly chronic low-mid level depression or dysthymia) in all cases, increases quality of life....Something I always ponder (whether to go back to just taking meds only on a severe/major episodic basis & during winter months instead, etc) as when psych meds were first introduced, I think the idea was that they were for episodic/short term use (in most cases).

If the interpreting cardiologist and my psychiatrist deem the results to be normal (assuming that the interpreting cardiologist finds nothing more of concern beyond the appropriate sinus tachycardia that appears to be present and that there is no overreaction to said appropriate sinus tachycardia (some doctors prefer to respond to any form of tachyarrhythmia aggressively irregardless of the rest of the clinical picture, but this relatively mild level of tachycardia present with the medication cocktail I'm on (the high doses of Fetzima and Adderall rather aggressively elevate norepinephrine levels, while the high dose of Adderall aggressively elevates dopamine levels as well, which both clinical data and structural mechanisms agree that this would generally cause a significant elevation in HR) and my history of anxiety (as well as my physical and family history) would generally/typically not be considered an issue requiring any response beyond continuing normal clinical monitoring and a repetition of the usual standard advice about best practices for exercise/managing stress/maintaining cardiac health), the medications will stay exactly the same as they are now.

If the results are normal but an aggressive response to the results is preferred for whatever reason, my psychiatrist would likely want to reduce the dose of the Adderall and/or the Fetzima and may refer me to a cardiologist for treatment (either in combination with or in lieu of reducing the medication dosages).

If the results are abnormal (i.e. if they find evidence of something genuinely concerning, such as atrial fibrillation, Wolff-Parkinson-White syndrome, atrioventricular nodal reentrant tachycardia, atrioventricular reentrant tachycardia, etc), my psychiatrist would most likely have me immediately stop taking the Adderall (and possibly the Fetzima as well) then follow up ASAP with a cardiologist for further testing. EKGs (technically I should really be using the term ECG or just electrocardiogram, but I'm stubbornly used to using the term EKG instead, which is still technically correct, and anyways I digress) have a relatively high rate of both false positive and false negative results (although it's highly variable), and the first step following most abnormal EKGs is to get more detailed/extensive testing done, with typically something like a holter monitor as the first step. If follow-up testing does not reproduce the initial results and does not result in any further abnormal observations, no further action would be required and I would most likely be returned to the previous regimen of medication. If follow-up testing does reproduce the initial results and/or results in any further abnormal observations, further testing may or may not be required, treatment is likely necessary, and depending on the ultimate diagnosis I may not be able to safely take certain medication (particularly psychostimulants) at all, or could only take them with extreme caution, ongoing monitoring and treatment, etc etc. But that's rather unlikely — if I had a genuinely concerning heart condition, one of the 3+ prior EKGs I've had would have already caught it unless it only developed recently or it was unusually excabarated by the current medication cocktail (rather unlikely given that I've been on cocktails in the past with far nastier observable cardiac effects (both in terms of HR and BP increases as well as physical symptoms) without anyone becoming concerned (and one of those prior EKGs was done while I was on a particularly nasty combination of high-dose methylphenidate, bupropion XL, and fluoxetine and was actively having a severe panic attack at the time).

The psychostimulant (Adderall) probably causes the greatest elevation in heart rate, followed by the Fetzima (obviously the combination of the two results in greater effects than either one individually, and the fact that I'm on the maximum dosage of Fetzima plus a technically above maximum dose of Adderall (although dosing guidelines for Adderall are vague, poorly defined, and not based on empirical evidence — an issue also seen with essentially all of the other psychostimulant formulations used for the treatment of ADHD, and one that has seen limited but persistent & significant discussion in the scientific literature, in official evidence + consensus based treatment guidelines, in medical textbooks, and in other sources) is going to make matters worse — the literature certainly shows a pretty consistent (although rather broadly variable, i.e. with a high standard deviation in results) dose-response relationship between increased HR/BP/side effects and increased amphetamine/methylphenidate dosage, and while the literature on levomilnacipran is considerably more limited, it shows similar trends (actually levomilnacipran is technically associated with substantially larger average changes in heart rate than amphetamine/methylphenidate, even at high doses, although I'm not sure how high the variability is for levomilnacipran). But the most important part is what your baseline heart rate off of meds is — if that's already persistently elevated (which mine was), it's generally only going to increase further on these kinds of medication, especially at higher doses — and it doesn't take much of an increase to go from a "high normal" reading to a "low abnormal" reading!

An EKG is a reasonably good initial cardiac screening tool, but for healthy adults (and children) with low cardiac risks, routine or screening EKGs are not recommended. This is why I said earlier "they could be a dick and reject it for being technically somewhat medically unnecessary if they wanted to", because professional guidelines for the treatment of ADHD don't really support the use of an EKG as a screening tool in cases like this, although I guess the complex polypharmacy in my case combined with the elevated heart rate, high dosages, and some other weaker semi-bullshit arguments would probably be enough to make a reasonably strong case to support the medical necessity of this EKG (however if the complex polypharmacy didn't exist the case would be relatively weak).

If you're concerned enough about the episodic palpitations/tachycardia that you've mentioned, you can talk to your GP about it and see what they think. They'll have a much better idea of your detailed medical history than I would, and would be best qualified to determine if some sort of cardiac testing (EKG, holter monitor, cardiac event recorder, etc) would be appropriate or not in your case. However keep in mind that testing is expensive and the kind of episodic palpitations/tachycardia you've mentioned are usually entirely benign unless they're unusually severe, persistent, and/or present with other concerning symptoms potentially attributable to a cardiac abnormality.

I'm just not able to function off of meds. No antidepressant = depressed & suicidal, while no ADHD meds = severe ADHD, depressed, and suicidal. No benzodiazepines = anxiety out of control. No HRT = gender dysphoria comes back with a vengeance. No PPI (pantoprazole) = gastritis symptoms return with a vengeance. Migraine meds (sumatriptan) drastically reduce the level and duration of decreased functionality due to migraines, and ibuprofen (which is what I relied upon before my current GP found out about my migraines, immediately wrote a RX for sumatriptan, and persuaded me that it was worth trying (I apparently had an extremely skewed perception about the point at which the severity, frequency, and controllability with OTC meds of migraines justified taking any kind of prescription-only medication for migraines, plus I was already rather overwhelmed with the number of meds I was on for other stuff)) is severely inferior to sumatriptan (alone and/or with ibuprofen) in efficacy. And without the temazepam my sleep is even more messed up. My therapist actually recently brought up the topic of potentially reducing the number of medications I was taking in the future, and I had to point out that I was already on essentially the bare minimum number already — the only thing I could potentially see being maybe able to eliminate under near-ideal circumstances was the antidepressant (and I guess I could dump the bicalutamide if I ever somehow managed to afford SRS (with the way things are going, it'll be fucking decades before that can happen), but that's literally it unless something miraculously and inexplicably drastically improved to the point where one of the other meds could be eliminated (ridiculously unlikely))...

My criteria are complex, but I'll try to describe some of them. If the side effects are consistently far too much to bear at any point and there are either no medications capable of practically alleviating/controlling the side effects (e.g. 30 mg escitalopram was intolerable) or if the medication to alleviate/control the side effects is ineffective or insufficiently effective, I dump the med (or reduce dosage if the effect came from an increased dosage (e.g. 30 mg escitalopram)). If the side effects are ridiculously extreme (e.g. when sertraline was added to existing methylphenidate (my first experience with any form of antidepressant), where I ended up with full-blown goddamn serotonin syndrome for a few days until I figured out what was happening and stopped the med (it was an astoundingly horrible and bizarre experience); the very nasty and thankfully short trials of AAPs olanzapine IR/quetiapine IR/ziprasidone IR), I stop the med as soon as possible. During the first 1–3 weeks on a medication (and for a similar or sometimes shorter time following dose increases) I generally automatically expect significantly worse side effects than at steady state, and will do my best to tolerate any nasty side effects during this period. If the side effects are still nasty after this period has passed and there isn't a major enough benefit to offset them, I drop the med (note that for medications with an extremely long half-life (e.g. fluoxetine) I will wait far longer than 1–3 weeks for the initial nasty side effects to reside and for effects to start to appear). If I don't notice any even vague positive effects from an antidepressant within a certain period of time that depends on the severity of side effects and how close the antidepressant theoretically is to being at steady state for the current dosage (a period of time that can be roughly calculated from the half-life of the drug and any relevant active metabolites, although with certain concomitant medications (especially any concomitant medication that inhibits any of the enzymes responsible for metabolizing the antidepressant) I will wait longer than this period), I'll generally either ask about increasing the dose (if the side effects are still tolerable and a higher dose is practical), or ask about switching to a different medication. If over the long term an antidepressant has only minor or vague positive effects, I'll eventually ask about augmentation and/or switching antidepressants. If an antidepressant's effects fade away to an impractically low level after a period of time and remain that way (e.g. vortioxetine), I'll ask about augmentation and/or switching meds once it's clear that the effects are poor enough and have remained that way for long enough (the exact duration is determined on a case-by-case basis, although a few days isn't long enough). Evaluating the efficacy of an antidepressant is very difficult, and I have a tendency to err on the side of caution if the side effects are tolerable and the depression isn't severe enough.

I do feel similar about tending to increasingly question the efficacy in the longer term. IDK, I feel like for most ADs, there's a significant initial placebo effect that fairly quickly fades with time, and the efficacy of the medication itself (or at least the perceived efficacy, which is approximately the same thing) also tends to wane with time...although the rate at which it does so seem to vary at least depending on the med, once it's useless it's generally not useful again even after a short (a few days to a few weeks) break (I don't think I've revisited an antidepressant med after a long break yet except for technically bupropion, which was a special case anyways), and some antidepressants' efficacy only wanes a little bit with time (Fetzima for example). Changes in environment or in other meds in my cocktail can also have a huge impact on the perceived efficacy of an antidepressant...

I've also wondered about meds possibly/potentially making my depression worse, but I generally resolve that conflict if possible by tolerating the med for as long as possible then eventually just switching meds, and with Fetzima at least it's pretty glaringly obvious that my depression is overall not worsened by the med (and if it's specifically worsened in some domain, I'm not very sure what that would potentially be). I could write quite a bit more about this topic but I've spent wayyy too much time typing up this reply already, I need to wrap this up and go to sleep...

Okay, last set of points to reply to. Primary efficacy-related drug trials required for FDA approval of psychotropic meds (focusing on antidepressants here) generally run for at least 4–8 weeks (more typically 6–8 weeks) as large double-blind placebo-controlled trials. A number of these types of trials are required for approval, as well as a few much longer open-label trials (often operated as extension trials as well) in which longer-term efficacy, safety, and tolerability is assessed over a period of over 8 weeks, and usually at least roughly a year (sometimes multiple years) for the longest trials (you need at least one ~1 yr long open label trial for approval plus at least a few 4–8 week long double-blind placebo-controlled trials and a pile of other shorter-term or more basic research plus a whole bunch of documentation and applications and proposed labels and other stuff, as well as FDA approval, which happens only once they're fully satisfied with everything — not only do they do detailed internal reviews of all the research and information associated with the information, they are also able to require additional research with FDA-set specifications from applicants if the FDA deems it necessary for the applicant to produce further research of any type and on any topic that the FDA requires in each individual case). As implied above, there are also a bunch of shorter trials done as well to test basic efficacy, dose-response, dose optimization, safety, tolerability, pharmacokinetics, etc prior to running longer trials, and there's always very substantial preclinical research done to obtain a broad variety of information on non-human subjects and in vitro. The overwhelming majority of drug candidates fail to make it to market, with failure rates increasing markedly at each stage (or more properly phase, a concept I won't discuss in detail) in the process. Overall, the FDA approval process is pretty damn thorough. If anything they are too conservative and stringent in a number of ways and areas. And they do require extensive post-approval monitoring and further trials as well. But the process is not perfect, and the benchmark for proving efficacy is lower for antidepressants than it is for many other medications due to the relatively uniformly very low effect sizes seen with pretty much all antidepressant trials.

It would be inaccurate to claim that efficacy is established based solely off of short-term trials due to the existence of (mandatory) long-term open-label trials. If you don't have at least one sufficiently well designed and run large open-label trial lasting at least ~1 year, it doesn't matter if you have 200 4–8 week trials, you're not going to obtain final approval from the FDA for your NDA.

It is also relatively inaccurate to claim that post-marketing reports or bad side effects are omitted, as all properly-conducted post-marketing trials and all reports of adverse effects from sources such as FARES will be taken into account by the FDA when it comes to subsequent post-approval monitoring, label/monograph revisions (the FDA gets a lot of control over these), additional post-approval research requests (the FDA's ability to require trials fulfilling certain requirements to be conducted by the applicant does not end after the drug has been approved), etc etc. All side effects that can be properly demonstrated to occur at even marginally significantly higher rates in patients taking the drug during trials are reported in the labeling/monograph, and are taken into account by the FDA. And the FDA is generally pretty good about ensuring that drug monographs/labeling contain enough relevant up-to-date information on most topics, although unfortunately not all of the topics covered are kept up to date, and due to limitations on length and the standard of evidence required a drug's monograph/labeling is never anywhere near perfectly comprehensive.

Yes, very-long-term research on antidepressants is a bit lacking, but because their effect sizes are so lackluster in the first place, it's rather hard to measure their efficacy in general, especially in less severely depressed populations.

Most psych meds are still officially intended/approved for short-term/medium-term use only irregardless of what actual consensus-based or real-world recommended usage durations are, and they pretty much all quite explicitly say in their product monographs that they have not been sufficiently evaluated for long-term use, etc etc. That doesn't mean that they aren't viable long-term medications.

I'd usually do some more research on what the current state of the science is on the evidence for long-term (as in decades to lifetime) use of antidepressants and discuss the results of that here at this point, but I've spent hours working on this and I really need to go to bed now in order to maybe get more than 3 hours of sleep before getting up to get ready for work tomorrow (at this point I'm unlikely to get more than 5 hours max :(...god I hope I get more than 3 hours tonight, I will be an utter wreck tomorrow if I don't). Hopefully this is a sufficient answer for your questions.

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Made some changes for the Spring/Summer. Depakote is staying the same for now, but we reduced the Trintellix and upped the Rexulti. Those changes were on 4/12 an 4/18. Then got to go on a Bahamas vacation to relax while all the changes happened, which went a lot better than I expected:

qAM

Trintellix (vortioxetine) 10mg

Vyvanse (lisdexamfetamine) 30mg

qhs

Depakote ER (divalproex sodium) 1000mg

Rexulti (brexpiprazole) 1mg

prn

Xanax (alprazolam) 0.25mg bid  -or- 0.5mg qd

Something interesting that I noticed in the DSM-V, the modifiers for major depressive episodes associated with bipolar 2 disorder have been expanded to include one for a "seasonal pattern", which effectively describes what I've been going through all my life, somewhere between Bipolar II and Seasonal Affective. When spring comes I become hypomanic which can have periods of irritability or mixed features, this may "rapid cycle" throughout summer time or I might just be consistently hypomanic until Fall when I start to crash from it all. It's just my seasonal rhythm I guess.

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Jesus fucking christ, the claim for the EKG just popped up in my insurer's claims portal and it's an adjusted amount of $225.35 (and because my deductible hasn't been met, I pay the full post-adjustment amount). That's...extremely painful... Apparently the previous info I was given by the hospital's billings department was mostly bullshit... To make matters (much) worse, the billing code being shown here is 93005 only, not 93000 or 93005+93010, so presumably I'm going to get another separate fucking bill under code 93010 from whoever they use for the interpretation and report (which will cost god knows how much more — probably somewhere around $100 if it's similar to the past, although 93010 has always been on the same bill as 93005 in the past, just as a different line item, so that's a bit confusing to say the least). Fucking brilliant. I still haven't gotten any info whatsoever on the test results, but since I'm only seeing 93005 on this claim, that means it's entirely possible that whoever they use for the interpretation and report hasn't even done the fucking interpretation and report yet, and I have no info from my psych to confirm or deny this...although odds are that the interpretation and report have already been done and sent to my psych and the claim for that will pop up in a few more days.

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Well I’m basically back to where I began medication wise. The zyprexa trial was a fail. Some meds are at a slightly lower dose. But I’m doing poorly so I don’t know if that is a good or bad thing. But I don’t wish to increase any of my antipsychotics because I’m having fewer side effects. I take the largest pill of abilify in the AM now. I’d like to add trintellix (an AD) but the bad nurse didn’t even ask my Pdoc so I’ll have to suffer until June to speak to my Pdoc about this. I’m very, very depressed currently.

 

Abilify 35 mg - mood stabilizer and psychosis......30 mg AM and 5 mg bedtime

Klonopin 3 mg - severe anxiety........1 mg AM, 1 mg afternoon, 1 mg evening/bedtime

Seroquel XR 600 mg - mood stabilizer and psychosis........600 mg evening/bedtime

Invega 6 mg - psychosis....6 mg AM

Lamictal 300 mg - mood stabilizer......300 mg bedtime

Yaz - birth control and heavy period control.......one pill AM

Nuvigil 200 mg - sleep disorders/wakefulness.....200 mg AM

Synthroid 25 mcg - hashimoto’s disease.....25 mcg AM

Metformin 2000 mg - weight gain prevention from psych meds.......1000 mg AM and 1000 mg evening

Topamax 200 mg - weight management/loss, controlling overeating.....100 mg AM and 100 mg afternoon

Lunesta 3 mg PRN - insomnia.....3 mg PRN bedtime

Vistaril 150 mg PRN - panic attacks or severe anxiety attacks.....50 mg up to three times daily PRN

Edited by Wonderful.Cheese

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Well I was finally able to confirm that the EKG interpretation & report was completed and that my psych received it over a week ago. The results were pretty much exactly what I expected: Sinus Tachycardia, otherwise normal EKG. Seeing as my psychiatrist hasn't contacted me despite having gotten the report over a week ago, I'm assuming that he isn't overreacting to the sinus tachycardia, so no med changes, no worries, everything worked out fine in the end...except for the cost, which is going to be quite high (I'm guessing it'll ultimately be up to $400 once the bills from the in-network cardiologist who did the report and possibly also their in-network electrophysiologist (I think his name was also on the report?) are added to the outrageous $225.35 that my insurer apparently thinks is a fair price for a outpatient EKG test without interpretation or a report (I'm still wondering how the hell they justify charging so much money when the machine setup cost them no more than $15–$20k at the absolute most (assuming a very high end model/manufacturer — the lowest-end machines cost as little as $1000), the test uses well under $5 of consumables, it's done by a technician that makes a bit less than a RN, and takes maybe 5 minutes to do...not to mention that Medicaid/Medicare would have only reimbursed them <$10 for this and if I was in Ontario OHIP would have reimbursed them even less! It's just bloody ridiculous all around...)). Oh and I still didn't get a copy of the report as originally promised, only a brief look at a scan of it thanks to my therapist — I'm probably going to have to formally request a copy either from the practice where my therapist & psychiatrist are based at, or from the medical group that did the testing/interpretation/report...

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Psych Rx:

Divalproex Sodium ER 1500mg [750mg bid] - main mood stabilizer ; anti-manic

Quetiapine 600mg -150mg q AM; 450 qhs -  mood stabilizer ; anti-manic; AD;sleep

Lorazepam 3,75mg qhs - anti-anxiety/sleep

Venlafaxine 150 75mg AM   - AD

Trihexiphenidyl 2mg q AM   - No need currently

Aripiprazole 15mg q AM   akathisia, too much activating

Non psych Rx:

 Perindopril 4mg q AM - blood pressure

Nebivolol 5mg q AM - blood pressure, sinus tachicardia

Esomeprazole 40mg q AM - GERD

 

Edited by centaurus

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Levothyroxine 75 mcg

Lithium 450 mg x2

Latuda 20 mg

Topamax 50 mg x2

Ritalin 10 mg x3

Klonopin prn 

I can't figure out if anything is making me extremely sleepy.  I've been on all of these meds before, but not in this combination, and my sleep doctor said that the effect of medications can't be ruled out because I was tested on all meds, including some I'm not on now.  I had an incident while driving and he changed my dosing of Ritalin but it makes me feel awful funky so I changed it back. 

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@Iceberg To my surprise I ended up getting billed a mere $33 for the ECG interpretation, which my insurer knocked down to $13.24, making this entire mess just $238.59. So it turned out quite a bit better than I was expecting in the end (I was thinking it'd be at least $300 at absolute minimum)... Not quite sure why they gouged me so ridiculously hard on the actual test, but whatever, it's basically over and done with at this point except for paying the bills...

Of course now a new and much nastier crisis has reared its ugly head to replace the EKG one (which technically isn't even fully finished as neither the hospital nor the cardiologist have bothered sending me their finalized bills yet even though both claims have been finalized) and now I've got to go figure out how to deal with this new bullshit (if I even can — this one might actually be bad enough to finally call endex on life for good, which is quite a pity given how things had been improving recently).

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Vyvanse 50 mg - QAM - ADHD

Adderall IR 10 mg - ADHD evening "booster"

Lamictal 150 mg - BID - Seizures

Sonata 5 mg - HS PRN - Insomnia

Trazodone 50 mg - HS PRN - Insomnia

Klonopin 0.5 mg - QD PRN - Anxiety

Xulane Patch - QW - Contraceptive/Regulating Menstural Cycle/Reducing Symptoms

Fioricet 50-325-40 mg - Q6H PRN - Migraines/Tension Headaches

 

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Psychiatric + neurological medications

  • alprazolam (Xanax) 1 mg 1 po x1 PRN - panic disorder
  • aripiprazole (Abilify) 15 mg 1 po q AM - bipolar disorder type II
  • desipramine (Norpramin) 50 mg 1 po q AM - bipolar disorder type II depression / ADHD-PI
  • dextroamphetamine (Dexedrine) 10 mg 2 po TID (60 mg) - ADHD-PI / bipolar disorder type II depression / hypersomnia unspecified / weight loss
  • doxepin (Sinequan) 10 mg 1 po qhs - insomnia
  • sertraline (Zoloft) 100 mg 1 1/2 po q AM (150 mg) - bipolar disorder type II depression
  • temazepam (Restoril) 30 mg 1 po QHS PRN - insomnia
  • ondansetron (Zofran) 4 mg 1 po x1 PRN - nausea (associated with migraine)
  • oxcarbazepine (Trileptal) 600 mg 1 po BID (1200 mg) - bipolar disorder type II / nocturnal epilepsy
  • prochlorperazine (Compazine) 10 mg 1 po x1 PRN - nausea (associated with migraine)
  • topiramate (Topamax) 100 mg 1 po BID (200 mg) - bipolar disorder type II / nocturnal epilepsy / essential tremor
  • zolmitriptan (Zomig) 2.5 mg 1 po x1, may repeat x1 after 2h - migraine

Other medications

  • Breo Ellipta (fluticasone furoate/vilanterol) 100 mcg/25 mcg/act DPI 1 puff qhs - asthma maintenance tx
  • lansoprazole (PrevAcid) 30 mg 1 po q AM - GERD
  • levalbuterol (Xopenex) inhalation solution 1.25 mg/3 mL (0.042%) neb 1.25 mg NEB q6h PRN - asthma rescue tx
  • liothyronine (Cytomel) 25 mcg 2 po q AM 1h ac (50 mcg) - hypothyroidism / antidepressant adjunct
  • montelukast (Singulair) 10 mg 1 po QHS - allergies/asthma
  • ProAir RespiClick (albuterol inhaled) 90 mcg/act DPI 2 puffs q4-6h PRN - asthma rescue tx
  • Victoza (liraglutide) 1.8 mg SC q AM - prediabetes

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Updates:

Effexor 225 - Depression & anxiety

Abilify 5 ->7.5->5->2.5 - OCD & tics

Ritalin 30 - ADHD

Reducing Abilify made me feel more alive and less flat. It also improved the notorious side effect of SNRIs (apologies to Cymbalta for blaming it on that)...

Anxiety and restlessness was still an issue. My pdoc suggested switching to a different AAP (Amisulpride) or try a mood stabilizer. I chose the second option, so:

Added Lamictal 25->50 (soon: ->100->200) - Magic powder.

Lamictal is amazing! I didn't believe it could be this effective at 25mg, thought it was the placebo effect. It's been a month, now at 50mg. OCD is pretty much vanished, tics almost disappeared, feeling calmer, sharper and more balanced than before. I don't even need Ritalin to stay focused (maybe once a week).

Took me a long time to find this combo and still naturally skeptical.

Never give up.

 

Edited by HydroCat
  • Like 1

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