Wait, increase, switch, augment?

[Catwoman]

Hi!

Today is my 28th day on sertraline. I have titrated up to 100 mg. I know these meds can take up to 6 weeks to work. Luvox worked for me with 5 weeks on 150 mg and I think I have been on 200mg as well. It pooped out so my second ssri was Lexapro, which kicked in faster at 3 weeks ( at 10 mg). After 6 years this one pooped out as well.

Last May, when the poop out happened, my general doctor was pushing new therapy and didn't switch me to another ssri, which I did not really like. He did increase Lexapro to 15 mg but after 4 weeks things were still the same and started the therapy and mindfulness classes. Meanwhile I slowly weaned off from the Lexapro, since I saw no use staying on it. I tried some alternative things like NAC, combined it with magnesium, vitamines, omega 3 and ginko biloba...but nothing really worked.

So after 4,5 months of being 100% medication free I asked my general doc for a consultation with a pdoc. The pdoc advised sertraline 100 mg or maybe a little more. A last ssri trial. I am extremely concerned that it won't kickin this week. I just can't imagine it doing anything. I know it is a bit too early to write it off and go on something else but I'd like to hear some opinions. 

The pdoc who does the consultations suggested (during the first and only appointment) a switch to clomipramine/Anafranil or augment with Seroquel (PRN dose, though I still don't know how this will help with stuck, unwanted repetitive thoughts) but only if Zoloft doesn't work for me. My general doc will follow this advice but I from everything I gathered there are so much more options...for example Prozac or adding Abilify or even nortriptyline. That pdoc said that more appointments with him arent possible. Which means I have to find another one...which can take weeks :-(

 

One last thing: the side effects I am having are almost unnoticable. Some RLS in the early morning, slight stomach irritation (1 of 2 times a week) and vivid dreaming. I had more anxiety the first two weeks and that's it...

 

I think I could go higher in dose without much trouble. But could a higher dose do the trick or do I supposed to feel something already? 

 

Sigh...I just want to get out of this situation...

Edited January 30, 2017 by Catwoman

[CrazyRedhead]

18 hours ago, Catwoman said:

I think I could go higher in dose without much trouble. But could a higher dose do the trick or do I supposed to feel something already? 

I'm certainly not a doctor, but I have found, from my past experience, that it's worth it to try and max out the dose of a current med before giving up and trying a new med.

In general, higher doses of the SSRIs are needed to be effective for OCD.....

In the case of Zoloft, the max dose is 200mg:........... https://www.drugs.com/dosage/zoloft.html

IMO, if your doc agrees, I think it would be worth it to titrate up to 200mg Zoloft, stay there for at least 6 weeks....Then if you still notice no improvement, it might be time to think about changing meds.

 

[iaawal]

Yes, I agree maxing out the dose and giving it sufficient time to work is the way to go. I didn't give up on my last med until I had been on the max dose for about 2 months. 

[Catwoman]

Thanks iaawal and CrazyRedhead! Really happy some people responded!

I couldn't reach my general doctor today. I think he will try to convince me to try longer at 100 mg...maybe he has a point but I can always go down again right?
In the past 10 mg of Lexapro was a effective for about two months and then I had to increase to 20 mg to get the same effect. These type of meds never really caused much discomfort, so I don't expect much trouble at 200 mg. I found people on these forums who go on ever higher dosages of Zoloft!

In theory Zoloft should be as effective as Luvox and Lexapro.
What really concerns me though....Upping my dose of Lexapro didn't work (so it must have pooped out) so how could Zoloft (the same type of medication) work? I even took a (stupid) drug holiday in the hopes it would kick in sooner...

Ohh well...I think going to the max dose is sensible for now. I would love to hear some more experiences from others though.

 

Edited January 31, 2017 by Catwoman

[mikl_pls]

In my experience, Zoloft didn't really kick in until 150 mg, but it really, really kicked in at 200 mg. YMMV though. Also, if Zoloft doesn't work, I'm for trying Anafranil.

[Catwoman]

1 hour ago, mikrw33 said:

In my experience, Zoloft didn't really kick in until 150 mg, but it really, really kicked in at 200 mg. YMMV though. Also, if Zoloft doesn't work, I'm for trying Anafranil.

Thanks Mik!

What would be a good titration schedule?
I started out with 25 mg and increased with 25 mg every week. Am I supposed to work my way up to 200 mg by doing the same for the next 3/4 weeks? Or can I go faster (no idea if that's a good idea or not)?





 

[mikl_pls]

2 hours ago, Catwoman said:

Thanks Mik!

What would be a good titration schedule?
I started out with 25 mg and increased with 25 mg every week. Am I supposed to work my way up to 200 mg by doing the same for the next 3/4 weeks? Or can I go faster (no idea if that's a good idea or not)?

2

You could increase by 50 mg every week.

[Catwoman]

Thanks Mik! I'll try that I think.

Unfortunately I have to wait for a little while since my general doctor isn't prepared to write a new prescription just yet.
He says I need to stay on the 100 mg for at least two weeks and then come by his office again to talk about dosage or new medication, unless I have an appointment with a psychiatrist.

Since I don't HAVE a pdoc I need to ask my general doctor for a appointment to see a new one...*sigh*

Currently I take 2 tablets of 50 mg so I would need 100 mg tablets....and he won't prescribe these yet...
I do have to pick up new 50 mg tablets tomorrow and I could increase dose by taking more tablets than I am supposed to...risking an argument with my general doctor....

 

[mikl_pls]

Maybe when you go see your gdoc, you could ask him to prescribe you enough for 150 mg so you can titrate up when you need to?

[Catwoman]

*Sigh* I'll think I'll wait it out. I have a talk scheduled with my counselor  (who also works for my gdoc and has a good knowledge of psychiatric medication) next week. 

I notice that I lowered my expectations of this SSRI... not having such high expectations anymore does help with being in 'the now'.
I hope it will kick in, but I don't feel so rushed. It sucks....but I can't do anything about it.

[Catwoman]

The last 7 days the Zoloft seems to be doing something. But there's also a big issue in the family right now which gives me stress and sometimes anxiety. This was extremely distracting me from obsessive thoughts. 

I'm taking Zoloft for almost 6 weeks now. It just doesn't feel the same as with Lexapro and Luvox.
I could really feel these kicking in!

Next week I'll send my gdoc a request for a new prescription of sertraline, but a higher dose and see how that goes.
If it doesn't do anything with 8 weeks I might try Prozac first before going on Anafranil.



 

[mikl_pls]

I'd recommend maxing out to 200 mg before switching, but then of course when you switch, your gdoc, without the extensive knowledge of a pdoc, will probably want to retitrate you from 20 mg Prozac, and you will have withdrawal symptoms. You'll need to be switched to 80 mg Prozac to be equivalent to 200 mg Zoloft.

But that's entirely up to you as to whether you do that or not.

Prozac is pretty nice, but know that it is rather stimulating and can sometimes exacerbate anxiety in some people.

Edited February 10, 2017 by mikrw33

[CrazyRedhead]

35 minutes ago, mikrw33 said:

Prozac is pretty nice, but know that it is rather stimulating and can sometimes exacerbate anxiety in some people.

@Catwoman, This is only my personal experience with Prozac, but it made my OCD and anxiety much worse, so had to stop it.........Not to say that would be the case with you, but it is the most stimulating SSRI I have ever tried....

[Catwoman]

23 hours ago, CrazyRedhead said:

@Catwoman, This is only my personal experience with Prozac, but it made my OCD and anxiety much worse, so had to stop it.........Not to say that would be the case with you, but it is the most stimulating SSRI I have ever tried....

Thanks for sharing! 

I thought Zoloft was the most activating / stimulating. It has more dopamine affinity than other SSRI's. At my current dose I don't seem to have any issues with feeling more active or anxious and my sleep is fine. With Luvox and Lexapro I didnt have much problems either, side effects I had were restless legs and teeth grinding. I have no idea if this means anything. But I'm much more scared of going on Anafranil than Prozac!

I wonder if Abilify could be something to add. When I was on Lexapro I was feeling quite sluggish and unmotivated in the mornings. Now the same with 100 mg Zoloft.

Oh and I' ll ask my gdoc for a referal to see a pdoc. I don't have much faith in just my gdoc handeling my medication. Even my counsellor agreed that 100 mg isn't much (he worked in the psychiatric field for years)

[CrazyRedhead]

17 hours ago, Catwoman said:

 But I'm much more scared of going on Anafranil than Prozac!

I wonder if Abilify could be something to add. 

Why are you so frightened to try Anafranil?.........In general, it is considered the gold standard for OCD.....Personally, I have had no major side effects from it, other than dry mouth when I first started it, but now that side effect has resolved.

Abilify is considered an atypical antipsychotic.......Just my opinion, but if I was in your shoes, I would rather try a TCA like Anafranil first,  before trying an antipsychotic.

I do take an antipsychotic (Thorazine) for anxiety and sleep, but your situation sounds a little different than mine.

In any case, I think consulting a pdoc is a great idea......IMO, maxing out the Zoloft at 200mg, and sticking with that dose for 6-8 weeks, before giving up on it, seems like the most logical course of action for now..........but a pdoc could have other suggestions.

 

Edited February 12, 2017 by CrazyRedhead

[Catwoman]

Thanks Redhead for your feedback on the Anafranil!

I think if I had to choose a new treatment and my choices would be between Anafranil and Prozac I would go for Prozac first. But I guess Anafranil is a better choice than Abilify as a mono therapy. So if I had to choose...And antipsychotics are completely new to me as well... From what I understand an AP more commonly used to augment an SSRI is Seroquel or even Haldol but I'm not willing to take that route just yet. 

Tomorrow I'm at the sixth week mark so hopefully my gdoc will just listen to me and have at least try out the maxinum dose.

 

Edited February 12, 2017 by Catwoman

[mikl_pls]

20 hours ago, Catwoman said:

Thanks for sharing! 

I thought Zoloft was the most activating / stimulating. It has more dopamine affinity than other SSRI's. At my current dose I don't seem to have any issues with feeling more active or anxious and my sleep is fine. With Luvox and Lexapro I didnt have much problems either, side effects I had were restless legs and teeth grinding. I have no idea if this means anything. But I'm much more scared of going on Anafranil than Prozac!

I wonder if Abilify could be something to add. When I was on Lexapro I was feeling quite sluggish and unmotivated in the mornings. Now the same with 100 mg Zoloft.

Oh and I' ll ask my gdoc for a referal to see a pdoc. I don't have much faith in just my gdoc handeling my medication. Even my counsellor agreed that 100 mg isn't much (he worked in the psychiatric field for years)

9

Zoloft is activating for some, but Prozac tends to be more activating for more people. It's a 5-HT2C antagonist which disinhibits dopamine and norepinephrine release. However, Zoloft's metabolite, desmethylsertraline, is actually a triple reuptake inhibitor. So go figure. YMMV. lol

Nothing to be scared of with going on Anafranil. I've never taken it, but the most bothersome side effect you may experience at first is sedation. But as the dose increases and the metabolite desmethylclomipramine increases, which is a potent norepinephrine reuptake inhibitor, you may find that you are more stimulated. Titration usually goes like this: start 25 mg, increase 25 mg/day every 4-7 days; max: 100 mg/day in first 2 weeks, 250 mg/day for maintenance treatment; info: give in divided doses with food during initial titration. However, some pdocs will titrate you differently, like they may titrate you slower than that.

If you're afraid of Anafranil and considering augmentation, I personally would consider antiglutamatergic compounds first. NAC you said you've tried before, but didn't have much luck with. Some examples of antiglutamatergics that are used for OCD in augmentation with SSRIs are topiramate (anticonvulsant), memantine (dementia drug), possibly tramadol, riluzole (drug for ALS), lamotrigine (anticonvulsant), and zonisamide (anticonvulsant). I may be forgetting some, but that's just a few antiglutamatergic meds. Some directly block glutamate receptors, some just block the release of glutamate.

[Catwoman]

Hey Mik, thanks for the interesting feedback on clomipramine I've always thought that if one SSRI works, then all others should work as well (but with different side effects) and I wouldn't have need for a less selective drug like Anafranil. 

Maybe I won't need it...I'll have to figure out what a higher dose of Zoloft is like first. I've been on 20 mg of Lexapro as well, it was quite effective!

I've read a lot about memantine. The pdoc Ive spoken to in January said it was an 'exotic' option. He wasn't really willing to prescribe it because I've never tried other antidepressants...But even if I could try it my insurance doesn't cover it because it's off label. It would cost me €3 to €5 per day!

Maybe Lamicital could be a possibility but my gdoc would never think outside the box...so I would definetly need a gdoc to discuss the glutamergic ideas.

[mikl_pls]

4 minutes ago, Catwoman said:

Maybe Lamicital could be a possibility but my gdoc would never think outside the box...so I would definetly need a gdoc to discuss the glutamergic ideas.

5

Print out some studies on the use of Lamictal for OCD showing positive results and bring them with you to your doctor's appointment, and present them to your gdoc and if you really want to try it, try not to take no for an answer.

[Catwoman]

I guess these waiting periods are the hardest for me. I don't trust my own brain anymore.

Though my variation of OCD is more obsessive (with just unwanted thoughts and no compulsions) I still have a hard time dealing with uncertainties.
I'm always coming up with 'Plan B's' and adding Lamicital is in fact a Plan B.

In spite of all the therapy I already had I still feel like I need a Plan B to stay calm.
Like: "There's always something to try if this doesn't work".
I need that reassurance. Maybe that's my compulsion.
 

In theory, all SSRI's work the same, but just with different side effects.

I wonder how it's possible that one SSRI works for a person, but another SSRI doesn't.

In my case, I have been on Luvox for some time and then on Lexapro for like 6-8 years. 
Lexapro suddenly stopped working (my unwanted thoughts came back out of the blue) and increasing dose didn't do anything. Why was this and did this cause Zoloft to be less effective or giving me no effect at all?

(Yes, I'm overthinking this, but it's interesting matter still)