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What's the next step?


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So where to start...

 

I'm kind of at a lost on where I want to go medication-wise.  My pdoc is very good, and I'm sure she has a plan of her own, but I like to go in armed with information and ideas of my own, which she's historically taken into consideration.  Dx is GAD with mild depression.  Have a history of one MDD episode in 2009 but not since. 

 

I've been on:
Paxil, up to 50mg/day - worked great first time (15mo), but didn't the second time (6mo)
 

Zoloft, up to 150mg/day - worked great for a little over a year but started to get really jittery on it and had to discontinue... whether it was med related or poop out is unknown (12 mo)
 

Lexapro, up to 20mg/day - inconsistent for the first 3 months then the same jiterriness that I experienced on the zoloft hit at 20mg (3mo)
 

Dropped Lexapro to 10mg and added Lamictal - drove me up the walls by the time I got to 75mg and had to get the hell off (1mo)
 

Lexapro with Amitriptyline - slept great but left me fuzzy all day.  GAD under control but still depressed. (2mo)

 

Finally, Effexor up to 112.5mg/day - seemed okay at first with sporadic improvements here and there but inconsistent at 75mg, tried 112.5mg for a little over a week but it started to cause anxiety and jitteriness that were unacceptably high.  Dropped back down to 37.5mg with a low dose of guanfacine for the anxiety surges that are occurring but I'm not satisfied with where I am. (last 3mo)

 

I've asked my pdoc about the possibility of BP2, but she has consistently denied it.  States there is no evidence of hypomania despite my reactions to lexapro, zoloft and effexor.  So really the only explanations at this point are that I'm ridiculously sensitve to something in these meds or they weren't doing anything to begin with and it's just my anxiety rearing it's head.

 

TBH, outside of these odd reactions I really haven't had any other indications of a manic/hypo episode in my past so I tend to believe my pdoc, but at this point I'm just exasperated.  The whole Lexapro/Effexor madness has been going on since February and I haven't had any significant level of stability since then.  I feel like I'm doing just enough to keep my head above water, but underneath it all I still struggle on a day to day basis.

 

So, given my med history and brain cooties, what might be the next logical step.

 

My pdoc has mentioned the other SSRI's, obviously, and Tofranil, but wanted to see what others had to say.

 

Thanks for taking you time to read my madness.

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If you have trouble with SSRIs, you might want to consider another class of drugs with antidepressant properties. Lamictal, lithium, and Abilify come to mind. You could also consider a TCA, which is an older class of antidepressants.

My pdoc did suggest augmenting w/ a low dose of lithium as well and wrote me a "just in case" script for it.  I hadn't heard much about it in the treatment of anxiety though.   I couldn't tolerate lamictal.  It drove me up the walls during titration and I couldn't handle it.

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What about seroquel? It helps me with anxiety. Maybe ask your pdoc about it?

I'm actually pretty curious as to why my pdoc has avoided the AAP's so far.  To be honest though, I think the effexor, even at this low dose is doing more harm than good, so I'm not too keen on continuing the augmentation route.

 

As of right now, moving to luvox or a TCA seems to be the primary plan.  I have a history of micturation syncope (fancy word for pee fainting) which has me concerned about the TCA class (all that orthostatic hypotension business), but they do tend to have a lower likelihood of insomnia and agitation.  THat's the problem with having options... having to choose. :( lol.

Edited by BusuB
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