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Help me decide: Lamictal plus which antidepressant that doesn't suck?

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The med tinkering is driving me nuts. Anyone with me here? Sigh. I have had depression and major depressive episodes for the past 20 years, but I have only been doing the med thing for the past three years. I feel like I get so close to finding a combo that works, albeit with some intolerable side effect... and then I try to get the combo better and wind up making it worse. My latest foray brought back my PMDD crying/depression/irritability for the past week and I'm just at a loss of what to do next. My psychiatric nurse is pretty much up for whatever I want to try, but I don't know what to do anymore. Maybe you all have some ideas?

Here's what I'm on right now: Lamictal 200mg (for MDD; *supposed* to be my main antidepressant), Wellbutrin XL 150mg (for giving me more energy and helping with my sex drive), and Lexapro 2.5mg (I had been up to 15mg, but completely lost my ability to orgasm and decided to go off it; hence going on Lamictal).

Dx: MDD, PMDD, Primary Insomnia (which may or may not be related to my depression)

Antidepressants I've been on:
1) Prozac: numbed me to the point of apathy, caused periodic limb movement disorder at night, sedated me
2) Zoloft 75mg: improvement over Prozac! actually helped me sleep through the night! Yay! Killed my ability to orgasm. Boooo! ... until I added Wellbutrin, then WOW! Sedated me so badly that I only survived on caffeine pills that I had to carefully time through the day, at 100mg every four hours. I hated the sedation (as in I would fall asleep wherever I was multiple times a day if I ran low or out of caffeine), so decided to try something else...
3) Wellbutrin 150mg: Added to help give me my sex drive back. Worked wonderfully! Love this one! Wish it still worked with Lexapro...
4) Lexapro 15mg: Swapped out the side effects. Caused periodic limb movement disorder like Prozac, but NO SEDATION! :-). Sadly, killed my ability to orgasm so completely that not even 300mg Wellbutrin could touch it. I could say that I could live with this, but the endless frustration in my relationship has made me want to pursue another option.
5) Lamictal 200mg: I started this in January of this year, for the purpose of getting off Lexapro, and have been titrating up ever since! Holy crap; it's been forever. Within that seven months, I tried to go off the Lexapro three times. The first two times, my Lamictal was at 100mg and I got down to 7.5mg of Lexapro before having a return of depressive symptoms. This past attempt at going off Lexapro, Lamictal was brought up to 200mg for two weeks before attempting to titrate down on the Lexapro. I titrated by 2.5mg every 5 days and I got down to 2.5mg before having discontinuation symptoms, including depressive symptoms along with headache, irritability, and nausea.

So now I'm at 2.5mg of Lexapro and have been holding there, afraid to go off it completely and afraid to go back up. Clearly the 200mg of Lamictal, plus 150mg Wellbutrin are not enough to deal with my depression, particularly the menstrual/hormonal version of it. I was at 200mg of Lamictal for 7 weeks before this last period hit, so I know that there was plenty of time for it to work. If I increase the Lexapro, it defeats the purpose of why I went on the Lamictal. I've never had good anti-depressant results from Wellbutrin, only increased energy, so no reason to go up on that. I am disappointed at the possibility that I've given Lamictal this entire year to work and I don't know if it is marginally working, or not really at all. I'd like to think that the reason I was able to get down to 2.5mg of Lexapro without return of symptoms this time means that the Lamictal is doing *something.*

Do I ask to increase the Lamictal? Go up to 300mg?
Do I add a different SSRI and go off Lexapro completely? Pdoc thinks I should try Zoloft again. Aaack! Must I live in a sedated state for the rest of my life?! I don't know if there is even the possibility that another SSRI would be better than Lexapro with the side effect profile. But maybe try Celexa and hope for the best?
Do I add an antidepressant that is not an SSRI, like Strattera, Abilify, etc....

Since I know y'all are going to ask, I have tried Mirena and Nuva Ring to control the hormone influenced depression and it has been a crap shoot. Mirena turned me into a raging bitch for months and I bled and bled for weeks at a time. So I had that taken out, needless to say. Nuva Ring caused weight gain, pimples, break through bleeding, and did not seem to make any difference with the hormonal depression. So I went off that too.

Talk to me, people. Lend me your ideas.

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10 hours ago, wren said:

But maybe try Celexa and hope for the best?

Celexa is too similar to Lexapro for there to be much of any difference. I wouldn't have much hopes in Celexa.

10 hours ago, wren said:

Do I add an antidepressant that is not an SSRI, like Strattera, Abilify, etc....

This is what I was thinking... Maybe try an SNRI, SMS, SARI, or an NaSSA.

SNRIs: Venlafaxine ER (Effexor XR) (Effexor has a terrible withdrawal syndrome, so approach with caution!), Pristiq (desvenlafaxine), Duloxetine (Cymbalta), Fetzima (levomilnacipran) (I'm currently having a terrible time with this medicine, so approach with caution!)
SMSs: Viibryd (vilazodone), Trintellix (vortioxetine)
SARIs: Trazodone (Desyrel, Oleptro), Nefazodone (Serzone) (liver toxicity scare is over hyped on this med... Depakote is more liver toxic than this med) (these actually help sexual problems)
NaSSA: Mirtazapine (Remeron) (OMG WEIGHT GAIN!!!)

However, there is one SSRI I don't see that you've tried, that is approved for menstrual issues, which is Paxil. It has a terrible withdrawal syndrome though, so I wouldn't recommend going there unless you really wanted to. It's also more likely to cause weight gain.

Another possibility is to create your own SNRI by adding a SSRI and a tricyclic together (usually one of the secondary amines), but this likely won't help your anorgasmia problems... The most common combination is nortriptyline (Pamelor) and sertraline (Zoloft), but nortriptyline can be replaced with desipramine (Norpramin) or protriptyline (Vivactil) which are both typically stimulating, or even the tetracyclic maprotiline (Ludiomil) (sedating!), and the SSRI can be swapped out with just about anything. You could even do an SSRI + Strattera for a cleaner SNRI-like action with less risk of weight gain. Doing this (with either a TCA or Strattera + SSRI) combination allows you to personalize the ratio of serotonin to norepinephrine reuptake inhibition ratio, unlike the fixed ratio of the SNRIs on the market, which are predominantly serotonergic (with the exception of Fetzima, which is more noradrenergic than serotonergic). Strattera on its own, however, would likely be unhelpful as an antidepressant.

Abilify isn't an antidepressant per se, but rather an atypical antipsychotic, but it does have antidepressant qualities, especially when used in adjunct with an antidepressant. Rexulti, Seroquel/Seroquel XR, and Zyprexa are approved for the same use, though it's not uncommon to use Geodon, Saphris, Risperdal, Latuda, and Vraylar like that too.

A sort of last resort could be the MAOIs—I tried  to do some research into whether they were effective for menstrual/hormonal issues but came up empty handed. This would include Emsam (selegiline transdermal patch), tranylcypromine (Parnate), phenelzine (Nardil), and Marplan (isocarboxazid). You have to do a 1-2-week washout period before taking these with no antidepressant (unless you've been taking Prozac, in which case the washout period is 5 weeks), which can be rough. Then if you ever decide to get off the MAOI and onto another class of drug, you have to do another 2-week washout. Plus there are dietary restrictions and lots of severe drug-drug interactions you have to really watch out for. They're a pain in the ass to take, but if they work well for you, they're well worth it!

10 hours ago, wren said:

I've never had good anti-depressant results from Wellbutrin, only increased energy, so no reason to go up on that.

You said you've only gone up to 300 mg of Wellbutrin before. Sometimes people need more than that. Sometimes people need as much as 450 mg or even 500 mg... This can be accomplished by taking either Forfivo XL 450 mg, Aplenzin 522 mg (bupropion hydrobromide instead of hydrochloride so dosages are different), or just simply taking generic bupropion XL 300 mg in the morning + bupropion SR 150-200 mg in the afternoon, which can actually be cheaper than taking the aforementioned brand-name products.

10 hours ago, wren said:

Do I ask to increase the Lamictal? Go up to 300mg?

Kinda answering your questions out of order here... lol. Well, you could go up to 300 mg. Do you have unipolar or bipolar depression? I've been on 400 mg, and there are people on as much as 600 mg and higher. Everyone is different. 200 mg may be the "magic" number for most people, but not everyone. Maybe you need 300 mg, maybe more. It's worth a try, but expect to experience some cognitive issues, or at least I did when I started ramping my dose up way high.

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FWIW ... In general, suggestions can help, but everyone reacts differently to medications.  Everyone's metabolism is different.   

Just because someone says one is safe (or not) (or is going to ... or not ... have certain side-effects) for another person doesn't necessarily mean another person will have the same thing happen to them. 

You won't know until you actually try the medication/s and give it/them long enough to work in your body (unless there is a serious interaction or intolerable side-effects). 


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Thanks for everyone's replies! So far, until I have figured out a new thing to try, I'm going to go back up on the Lexapro--because I know that it works on the depression and the only side effect that I hate is the anorgasmia. It's a big one, but perhaps it will be solvable with the addition of another med? I am still looking at the options for switching off Lexapro to another SSRI.

TACP - will check out Effexor. Not sure i'm up for the withdrawal symptoms, but will definitely consider it.

Micho - I'm thinking of upping the Wellbutrin again, just to see if that helps recover my ability to orgasm

Melissa - Yup. Everyone's different. I just need a direction. I know it's all a grand experiment.

Mikrw - Dang. You have a brain med encyclopedia in your head. Overwhelmed by the options! Remeron is out. Not going to gain weight, since I have already gained 20lbs in the past 3 years. Trazadone... I thought most people used this as a sleep remedy; since I have a tendency to be sedated by just about everything, I am afraid to even go near this. I will look into the other combos you suggested. In response to your question, I am diagnosed Major Depressive Disorder, Premenstrual Dysphoric Disorder, and that great catchall: Generalized Anxiety Disorder. Also, Primary Insomnia. My psychiatrist speculates that while she thinks I am more unipolar, that I brush up on the edge of bipolar, if there were a spectrum. My brother is diagnosed Bipolar I and there is a family history of bipolar disorders on both my mom's and dad's side. I do have a tendency toward cyclic depression that is heavily influenced by low light (winter months) and menstruation. But, I am also depressed at other times of the month besides my period and I am depressed at other times of the year besides just winter. It's just those things make it *worse*. Ha!

Question! If any of you have been prescribed Abilify, what was the purpose and did it work?

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I am prescribed Abilify for major depressive disorder, and man, did it ever work! I love it. If you don't like sedating meds the odds are you won't be sedated by it (though some are somehow). I gives me energy and real motivation and an interest in life back. I can't say enough good about it. For me it really does work as the commercials said it would.

The only drawback that I experienced from it was horrendous anxiety at low doses, but once I got above 10 mg the anxiety went away and it really kicked in.

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I found Wellbutrin the only reverse up take drug I could stand to be on...

The serotonin (not Welbutrin) variety caused all kinds of anxieties I never new I had and was exhausting fighting through them. Additionally the serotonin variety caused problems including difficult urination

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