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What to try next – venlafaxine or imipramine/fluoxetine?


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Sorry for the long post. Maybe too much background.

My Pdoc seems to be running out of med options to try. I've been on various TCAs and SSRIs for depression off and on for about 45 years. Many gave me a lot of side effects but no dramatic improvement. Buproprion worked well a couple of times I took it (should have just stayed on it).

Over the last 2-3 years, my resilience has been whittled away and my anxiety also increased, but I'm one of the lucky ones for whom buspirone actually works well to keep a lid on it. I was also diagnosed with ADHD (inattentive) and methylphenidate keeps me from going round in circles trying to do 5 things at once.

As life continued to take its toll, my motivation and energy dropped through the floor. So last year I tried buproprion again, but instead of working the way it did before, it made me irritable and increased my jaw clenching and tooth grinding a lot and didn't do a lot to improve mood. Next was escitalopram, but it also didn't help my mood and still exacerbated the jaw clenching and the nausea/queasiness wouldn't go away.

So, 7 months ago I started taking 10mg of fluoxetine per day, a very small dose, but I'm sensitive to many kinds of medications. It seems that the fluoxetine has been making me even more tired. Sometimes it makes me feel stoned and I can't think or that I'm about to fall over. Now I haven't wanted to do anything at all. I'm not working (self-employed). I don't even want to go out of the house, and feel that I'm letting people down by not being able to fulfill the things I should be doing.

For the last month, reducing the dose of fluoxetine to 5mg/day (the dissolving in orange juice trick) has helped a little, but not much. At least I don't feel like I'm going to fall over.

My Pdoc doesn't think that going back on buproprion is a good idea because of the reaction I had last time. He has suggested venlafaxine several times, but I was afraid to try it because of all the horror stories about getting off of it. This time, as an alternative to the "v" he suggested adding imipramine to the fluoxetine. He mentioned going slowly and cautiously and having to monitor my blood levels to make sure they don't build up too much TCA, since fluoxetine interferes with TCA metabolism. This is scary stuff too.

At this point I really want to get off the couch and feel like doing something else besides waiting to die. I'm trying to make some changes to improve things, trying to revive old interests, and have an appointment with a new therapist in 3 weeks. I still need to be on some meds, but they can't make me want to sleep all day and night or be in a fog and unable to think clearly. Of course it would be nice for my weight to balloon up more than it has (+30lbs over 2 years, almost back to my all-time high).

I've done a lot of research (hyperfocusing) on the computer, but can remain undecided forever. Does anyone have any opinions as to which seems the best next step – the venlafaxine or the imipramine/fluoxetine combo? Is there anything I'm overlooking?

Thanks in advance for your help.
 

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I personally find venlafaxine very helpful for my depression, but it took 300 mg + Abilify to conquer my depression. 

 

So, obviously, YMMV. 

 

Has your pdoc considered adding Abilify? Or another antipsychotic? Or possibly a mood stabilizer like lithium, Lamictal, carbamazepine etc? Based on your signature, you still have lots of options left. :)

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Hi Paraluie. Thanks for your suggestion. It's great that you've conquered your depression. Hopefully, one day I'll be able to say the same.

 

My pdoc hasn't suggested a mood stabiliser or AP yet. I've wondered about them, but they're usually AD add-ons and I've focused on first finding any AD (or two) that does something. But if this next round doesn't work, I probably should ask about adding a stabiliser or AP. Have you had any side effects? Ever try to get off?

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Hi Paraluie. Thanks for your suggestion. It's great that you've conquered your depression. Hopefully, one day I'll be able to say the same.

 

My pdoc hasn't suggested a mood stabiliser or AP yet. I've wondered about them, but they're usually AD add-ons and I've focused on first finding any AD (or two) that does something. But if this next round doesn't work, I probably should ask about adding a stabiliser or AP. Have you had any side effects? Ever try to get off?

 

I've never tried to get off of venlafaxine, but I hear it's torture, unfortunately. When I forget a dose, I get body zaps and headaches. The only initial start up side effect I had was urinary retention that wore off in a week.  

 

Abilify has literally been a Godsend for me. It has changed my life. It took care of my depression in three days flat. It keeps my psychosis under control and so far I haven't had any hypomania on it either. It really is my wonder drug. I had some initial start up side effects like akathisia and hypomania. The hypomania wore off in a week, and the akathisia was taken care of with a small dose of propranolol. I'm at 30 mg of Abilify now, I have no side effects other than being kinda sleepy. But, it's manageable. 

 

I know AP's and mood stabilizers are usually AD add-ons, but maybe an AD won't work for you until you add something. I hope that isn't the case, cause the less drugs the better. But hey, if you need them, you need them. 

 

I hope you can find an AD that works for you soon, I'm so sorry you've been suffering for so long. :(

 

Edited to add: Abilify also completely took care of my GAD, something I see you deal with as well. My GAD is gone. It's incredible, considering I've had GAD since I was 4 years old. 

 

I know, I know, I'm a commercial for Abilify. :P

Edited by Parapluie
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Thanks, Parapluie. I'll keep Abilify in mind as a possibility in the future.

 

For now my pdoc is prescribing 25 mg imipramine at bedtime and keep the fluoxetine at 5mg/day. He says that the effective dose level will increase over the first week or so, even without changing the dose, since the fluoxetine will inhibit the metabolism of the imipramine. I'm starting tomorrow and hopefully the combo will work and the sides won't be too bad.

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I asked to go on nortriptyline for my depression, and it worked pretty well for the time I was on it.  My doctor didn't like me being on an old TCA, and suggested an SNRI so I switched to venlafaxine a week ago.  So far I can't tell a difference except for that I'm a little more energetic and yawning more (hah), but I can't realy comment on what's necessarily better yet.  I know you're talking about imipramine, not nortriptyline, but they're both TCA's. 

 

It seems so far, though, that venlafaxine is pretty good at sustaining the chemicals, and it's a whole lot better and safer on the body/heart than TCA's

 

Hope this helped.

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I was on venlafaxine for many years and I just want to say that that it is not hard to get off for everyone. Don't let that put you off. I had no trouble with going off it. It think it gets an unfair bad rap for that. My pdoc tapered me off over a few months and everything went very smoothly.

 

I was previously yanked off it because of a manic episode and also didn't have problems with that.

 

Just an experience from the other side.

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kittybrain,  we are really very similar in our history.  i have spent a lot of time feeling like a waste of space just waiting to die.  not leaving the house, not bathing....etc.

 

 i have been on and off every med for depression since I was 20...I am 61.  in and out of therapy, social phobe since I came out of my mothers womb.  

 

When I worked as a special ed. teacher and case mgr. I worked with asbergers and autism and I think I could have been diagnosed with one or the other had there been such an illness back in the 1950's!  It is a battle to engage in life and interaction with others. Parties, small talk, mingling...I get panic just thinking about it.

 

So I read the imiprimine is a good drug that works for those who have a depression that seems to have become drug resistant.  My fingers are crossed for both of us.  I have never had seratonin syndrome and don't want it.  I will pay very close attention to the fluoxetine and the imiprimine, although I don't start that 10mg dose until next week, after I am done with wellbutrin.

 

We are a bit different as I will be on 40mg fluoxetine and 10mg of imiprimine.  I don't think we should worry about this combo.  I have read and heard the imiprimine will have a positive effect quickly...within a week. Unlike the SSRI's that one waits for 4-8 weeks to know if it is working.

 

Keep us posted.  I am personally very interested in your case as it is similiar to mine.  

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@eternal sun & @Luna – Thanks for the good reports on venlafaxine. If the imipramine doesn't work (or I can't tolerate it), that will probably be what we try next (or adding something like Abilify).

 

 

@gringatica – Thank you. Yes, I also hope the imipramine works quickly, and we'll have to compare notes as we go along. Hey, we're the same age! And sounds like a very similar history with these things.

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kittybrain, I have not strarted my imiprimine. I am scared somewhat about maybe the wellbutrin not being out of my system and if it is safe yet to not be taking it, and if it is safe to start the imiprimine.  i don't trust the pdoc i saw, he said i could take wellbutrin every other day, and then start the imipr.  then i read that is NOT how to come off wellbutrin...it is scary to me.. and i don't want to take the added 20mg of prozac as i think 40 would make my hair fall out even more than th e 20mg.  i usually second guess a pdoc when i don't think they know much.  i need to know how to kick start this.

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When your doc run's out of options for SSRI, SRNI's can he go with maybe another stimulant. I know you said your on generic ritalin but maybe dex will lift you up if your not to scared of SE's. I know it can be stressful. I am on effexor and even tho I get agitated sometimes...I am in a better mood. 45 years is a long time. I'm so sorry you have had to go down this road.....PM me if you want to talk......Since I take effexor I am happier.....And alot more motivated.

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  • 2 weeks later...

Sorry for not replying for a while. Social media isn't a strong point, but I'll try to be better at it. I wish the notifications worked; they're really helpful reminders.

gringatica – How are you doing now? Are you still on the wellbutrin? Have you switched to the imipramine? I agree with your hesitancy about doubling the prozac, especially if you're switching from two other drugs at the same time. One change at a time seems more reasonable.

@sonicwhite – yes, that's why my pdoc was suggesting venlafaxine. But imipramine touches on NE as well as SRT, so maybe that's why he suggested this to try first. It's good to know that you like others are having good results with effexor. If this round doesn't work that's the next one I'll try. I've also tried adderall, but had more side effects with that.

@eternalsun – I wondered about provigil, but hadn't asked about it yet, because I know the depression still needs to be addressed.

Anyway, I've been taking the combination of 25mg imipramine with 5mg of fluoxetine for 3 weeks now and started noticing improvement after 1 week. Last week the Pdoc said to keep at this level for another 2 weeks and check with him again next week to see if anything should be modified. Perhaps drop the fluoxetine and increase the imipramine? I'm sometimes tired, but it feels more like normal fatigue, not the heavy, leaden fatigue or feeling like I'm drugged into a stupor. I'm generally more alert, feeling less down and more apt to get things done (still inconsistent). Maybe a little more anxious, but that might be situational. There's been very few side effect issues at this low dose.
 

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Hola Kittybrain.  I have been thinking of you and I haven't checked into the forum in a while.  I am still doing the 10mg of imiprimine at bedtime, with the 400 of Neurontin for my TMJ pain, and doing only 20mg of Proxac/flueoxitine in the a.m.

 

 I am off the Wellbutrin and I must say that compared to coming off Lexapro last Oct. it was a cakewalk.  Very few bothersome symptoms of withdrawal.  Some headache, some vertigo, but once I was off it, it was no big deal.

 

I am feeling like the imiprimine is working, I knew wellbutrin had stopped working for me.  I'd been on it forever. I don't see the pdoc until end of august, so I guess I will just do what I'm doing until then.  They filled the script with 10mg imiprimine instead of his written script of 25 mg.  I get a refill next week, so I will talk to the farmacia about that.  Could have been their error, although I am o.k. with starting low and adding on later.  Especially knowing the fluoxitine increases effects.

 

I think I am getting from your post that you are better.  I know my depression is not so dire. This may be about as good as it gets!  Socially, I am getting out of the house a bit more, still not bathing but 1x every 4-5 days.  My husband and I have travel plans to go to Montreal and then Denver and Texas in July for visiting family.  I may need the clonazipan drops for that.  Even just one drop in a spoon of water can make a difference in my anxiety.

 

I am still picking my scalp.  oh well. want to hear from you! 

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Hi gingratica. I'm glad it seems you're starting to feel better. How long have you been taking the imipramine? Maybe the farmacia did make a mistake, but it's better to start at too low a dose than too high. You can always increase it later. We both on low doses and haven't been taking it very long, so this is just the start of feeling better. I'm sure it's not as good as it gets yet.

 

My mood has definitely been improving, but the anxiety/avoidance about some things is still there. I'm going update my pdoc tomorrow, so we'll see what he says to do next. That's the problem with having multiple diagnoses and needing to take different meds for different things. Sometimes you change one thing and then need to rebalance the others.

 

I wish I could help you with the scalp picking. I don't know if that is related to anxiety and/or OCD, but maybe someone else in the OCD or another forum has some suggestions. Have fun on your travels.

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hey girl,  the past 4 nites I upped my imiprimine to 20mg and now tonight I am going on the 25mg.  the farmacia filled it correctly this time.  I am almost to a month on it.  seemed like I was really noticeably better initially, but some of the honeymoon effect is over.  

 

Still hard to motivate out of the house, to do things with others, to take a shower.  but I think the depression compared to jan feb march...way better.  I really bottomed out.  I am in this for the long haul, don't much like switching meds and the whole wait and see trial and error.. I will say my appetite is low.  Thinking I'm losing some%

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