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20mg of Lexapro did nothing for me!

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Hi all 

I took lex 20mg for about 2.5 months but it seems that it didn't work at all for my social anxiety and motivation. it's supposed to be the best ssri! so why it didn't work ? do i have tolerance to antidepressants ? will switching to another AD help ? I appreciate your help guys

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First, I have to say that Lexapro is a poor choice for motivation in my experience and a good choice for social anxiety. Both Lexapro and Celexa give me a great deal of apathy while at the same time relieving my anxiety so it's kind of a mixed bag for me. Abilify does help a lot with my motivation, however.

I can't answer why Lexapro didn't work for you. There really is no "best" SSRI as it all really comes down to your particular brain chemistry. A lot of people with bipolar disorder have problems with SSRIs so that could possibly explain your reaction but not entirely because I am not bipolar and I went through all the SSRIs and only Celexa (and Lexapro) helps me.

I think it is definitely worth trying other antidepressants if your pdoc agrees. Some, like Wellbutrin, are known to play nice with bipolar although Wellbutrin would probably do little for social anxiety.

Have you tried Remeron (mirtazapine)? That's a very good antidepressant for anxiety once you get over the initial sedation which is considerable. 

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  • 2 weeks later...

I agree with everything jt07 said.

Lexapro isn't the best med for motivation. I experienced quite a lot of apathy while on it too. Abilify can indeed help with motivation though.

Like jt07 said, there's not "best" SSRI, it depends on your individual brain chemistry. You will have your own response to each antidepressant that is unique to you (perhaps similar to others in some ways, but not everyone responds exactly the same to a particular medicine; e.g., some people are stimulating by Cymbalta, some are sedated by Cymbalta). 

Since you have an anxiety disorder, you may need an even higher dose of Lexapro (high doses of SSRIs are reserved for anxiety disorders, while low doses are reserved for depressive disorders). You may need 30 mg or even 40 mg of Lexapro for your social anxiety to adequately respond to the Lexapro.

Otherwise, there are a number of alternatives for you to consider.

  • Fluoxetine (Prozac): [20 mg] Start: 10 mg x1wk; max: 60 mg/day (80 mg) 
  • Sertraline (Zoloft): [50-200 mg] Start: 25 mg x1 wk, then 50 mg, then may incr. by 25-50 mg/day every week; max: 200 mg/day (although some go higher)
  • Paroxetine (Paxil):
    • instant-release form: dose: 20 mg; start: 20 mg, may incr. by 10 mg/day every week; max: 60 mg/day
    • extended-release form: dose: 12.5-37.5 mg ER; start 12.5 mg ER, may incr. by 12.5 mg/day every week; max: 37.5 mg/day ER (though I'm sure you could go higher)
  • Duloxetine (Cymbalta): [60 mg] max: 120 mg/day; may start 20-30 mg x1wk if tolerability concern, may incr. dose in 20-30 mg increments
  • Venlafaxine ER (Effexor XR) [75 mg ER] no proven additional benefit at doses > 75 mg/day (it's basically just a SSRI at 75 mg, it becomes a SNRI at around 150 mg, I'm sure higher doses are used for people with social anxiety who take this medicine) (if startup anxiety is an issue, could start at 37.5 mg)
  • Phenelzine (Nardil) (MAOI) [15 mg every other day-15 mg 2x three times per day] Start: 15 mg three times per day, then increase rapidly to 60-90 mg/day in divided doses and continue until clinical response, then decrease slowly over several weeks to lowest effective dose; max: 90 mg (sometimes more)

Prozac and Zoloft usually tend to be very activating, so they may have initial startup anxiety, that's why it's best to start with the lowest dose possible and titrate slowly (probably slower than I mentioned above, I copied all that from Epocrates, modified a few things slightly). Effexor and Cymbalta tend to be quite activating too, but may also be sedating for some people. But chances are, if you have motivation issues, these would be some of the best 1st line agents for you.

Nardil is an irreversible MAOI, which means you'd have to follow a low tyramine diet and watch what other meds you take (like you wouldn't be able to take Tegretol with it due to its contraindication). But MAOIs have been prescribed with great success for social anxiety disorder, and may help with motivation as well too. Nardil may actually be a little sedating for most people. Two other MAOIs, Emsam (selegiline transdermal) and Parnate (tranylcypromine) may be more activating without the sedation and may assist with both anxiety, depression, and motivation. Emsam is unique in that the lowest dose, the 6 mg patch, doesn't require you to follow the low tyramine diet. The 9 mg and 12 mg patches require it though. Parnate requires a low tyramine diet no matter what dose. These are also less prone to causing weight gain than Nardil or Marplan (isocarboxazid) (don't know if that's an issue for you). Don't know if you'd be up to going to the trouble to switching to a MAOI, but thought I'd mention them anyway since I don't know what your medication history is.

I agree with jt07 in that mirtazapine (Remeron) is a good option too, possibly as an adjunct to Lexapro, or to switch to if you'd rather ditch the Lexapro. The lower doses are more sedating (7.5-15 mg), while the higher doses can be more activating (30-45 mg and beyond in some cases).

Some augmentative medicines to consider:

  • Gabapentin (Neurontin, Gralise) [300-1200 mg three times per day] start: 100-300 mg three times per day; max: 3600 mg/day
  • (Lyrica I'm sure would also do...)
  • Alprazolam (Xanax) [0.25-1 mg three times a day as needed] start: 0.25 mg three times a day as needed, may incr. dose every 3-4 days; max: 4 mg/day
  • Clonazepam (Klonopin) [0.25-0.5 mg two to three times a day] start: 0.25 mg twice a day, may incr. by 0.25 mg/day every 1-2 days; max: 4 mg/day
  • (I'm sure any benzo would do...)
  • (For some reason Epocrates mentions lithium and Depakene...?)

Another augmentative medicine would be a beta blocker, like propranolol (Inderal).

Hope some of that helps!

Edited by mikrw33
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