Back on the med-go-round and hoping for some guidance

[Ion]

I've dealt with depression and anxiety for 16 years. I was treated for a few years. I found a lot of meds that didn't do much and a few that were really terrible (Effexor and Depakote), but then I lost access to those doctors and I've been untreated for the last 10 years. I've done a ton of work on lifestyle changes and my depression is now moderate rather than severe, but it's also never ended, so now I’m getting help again. The symptoms that bother me the most are anhedonia and low energy/motivation. I also have poor memory and concentration.

I’m currently on citalopram 20mg. I started it 3 weeks ago, and the first week was 10mg. Most of the side effects have been transitory or manageable, but so far a continuous one has been apathy and it’s currently making things worse than before. I’ve still got weeks or months to really answer if citalopram will help, but I’m also planning my next step if it doesn’t. I’m trying to think about how to identify meds that are a good fit for my symptoms so that I can have constructive conversations about it with my GP who prescribed the citalopram and the pdoc I’ve been referred to. I’d really like to reduce the amount of trial and error compared to last time. I’ve been reading a lot and the meds that have jumped out at me are Zoloft or Prozac, Abilify as an adjunct and Wellbutrin. 

I know this is a pretty open ended post, but does anyone have any thoughts? Getting treatment is a huge part of my life right now and I want to be able brainstorm.

Thank you

[Iceberg]

The problem is it's hard to tell what you'll be treating until u let the celexa work for a few more weeks...then I would look at the abilify or Wellbutrin as an add on...Zoloft and Prozac are pretty similar to celexa and you'd have to do another titration. Also rexulti is an option ...but again, after the celexa has more time 

[Flash]

Yes. I had the genetic testing done a little while ago, and it has really been helping. I'm not 100%, but I'm a hell of a lot closer to it since the testing. I'm not saying it's a magic bullet, but it's something worth considering. I know some people here have little faith in it, but I've known a number of people to get good results from it, including myself. 

[Iceberg]

Can I ask why Zoloft or Prozac? 

[jt07]

Yeah, citalopram can really make you apathetic. I like to say that it even makes me apathetic about being apathetic. This side effect has not gone away for me, and I've been on it for 10 years or more. Still it is the one med that helps my anxiety the most and the only SSRI that has had a significant impact on my depression.

Any reason why you are choosing these meds and not working with a psychiatrist? I think your psychiatrist should have input as to what your next step would be.

However, having said that, adding Abilify to my cocktail largely knocked out the apathy from my depression and from the citalopram. It also had a MAJOR impact on my depression.

As far as Prozac goes, it made me so angry that I would rage. Zoloft was more helpful but still let me down in the end. I think I got one or two really good days from the Zoloft or maybe those were flukes.

Good luck on the med-go-round!

[Ion]

Thank you for the replies

1 hour ago, jt07 said:

Any reason why you are choosing these meds and not working with a psychiatrist? I think your psychiatrist should have input as to what your next step would be.

I have an appointment scheduled with a pdoc (still a way off, unfortunately) and my research is so that I can be informed about the things they suggest and be able to advocate for the things I think are important, which is more about specific symptoms than about specific meds, but I still want to know how it fits together so I can make the conversation as useful as possible.

4 hours ago, Iceberg said:

The problem is it's hard to tell what you'll be treating until u let the celexa work for a few more weeks...

I know I've got a while on the citalopram still. I could very well start to see some improvement from it in the next weeks/months and the apathy might not be a lasting side effect for me. I remind myself that it still has time to work but I'm also not particularly optimistic. It's one of the ones I was on with no significant effect 12 years ago. I was also on Paxil and Prozac in that time period. Having ideas of other possible meds that could be tried later helps me feel less discouraged and makes it easier to get through the process of trying the citalopram.

1 hour ago, Iceberg said:

Can I ask why Zoloft or Prozac? 

I was reading that they were the more activating of the SSRIs, and since low energy was one of my top two symptoms, I thought that might make them the better choices in the SSRI category.

2 hours ago, Flash said:

Yes. I had the genetic testing done a little while ago, and it has really been helping. I'm not 100%, but I'm a hell of a lot closer to it since the testing.

It certainly sounds interesting. Can you point me toward anything to read about how the genetic info actually gets used in treatment?

[Iceberg]

Have you tried SNRIs? There's some newer ones that can be activating

[mikl_pls]

Actually, Prozac and Zoloft are nothing like Celexa. Celexa is a straight up SSRI with slight antihistaminergic properties, Prozac is an SSRI with 5-HT2C antagonism and thereby making it a norepinephrine-dopamine disinhibitor, and Zoloft is an SSRI wish slight dopamine reuptake inhibition and σ receptor binding properties. All-in-all, they're all SSRIs, yes, but they all have their own unique pharmacology. Prozac and Zoloft are good for anergic depression, atypical depression, etc. low energy, oversleeping, overeating (especially Prozac for this one).

I think adding Wellbutrin and/or Abilify would be an excellent option, but I don't really think Celexa is a match for your symptoms. I could be wrong, but Celexa is a very mild and somewhat sedating antidepressant that, like Lexapro, seems to make the one taking it a bit apathetic.

SNRIs are great too, like @Iceberg said, as they tend to be stimulating, but for some, for some reason, they can be sedating. It all has to do with your basal norepinephrine levels. If they increase your norepinephrine too much, it can make you sedated from what I understand.

Abilify worked pretty well for my mood, didn't completely eliminate my anhedonia but came pretty close to it. Rexulti I didn't have such great results with, but YMMV.

[Geek]

Since you have experience with limited to no response to SSRIs, if your doctor decides that the Celexa isn't working, rather than another SSRI like Zoloft or Prozac, I'd push for an SNRI like Effexor or Cymbalta (don't worry about discontinuation syndrome, lots of people don't experience it). You've failed enough SSRIs at that point, try something that will work differently. Some people find Wellbutrin activating also, it's a good thing to try too. 

If you get some response but not satisfactory it is pretty common to supplement with Abilify or Lamictal. I wouldn't push for Rexulti, which is similar to Abilify but unlike Abilify only available as a brand name drug. Try Abilify and only do the Rexulti if you need a bigger boost or something.

[Ion]

55 minutes ago, Iceberg said:

Have you tried SNRIs? There's some newer ones that can be activating

The only SNRI I've tried was Effexor

The full list from 10-12 years ago is: Citalopram, Effexor, Paxil, Lorazepam, Prozac, Risperidal, Divalproex, Buprioprion. Most didn't seem to do much that was helpful and had varying degrees of side-effects. I had a bad experience with Effexor and with a combination of Fluoxetine/Risperial/Divalproex (based on the bad side-effects, I think the Divalproex was the culprit, but it's impossible to say for sure)

7 minutes ago, Geek said:

You've failed enough SSRIs at that point, try something that will work differently. Some people find Wellbutrin activating also, it's a good thing to try too. 

I definitely don't want to spend the time to try most or all of the SSRIs again. I'm open to trying a second one on this time round (if that's what the pdoc wants), but if 2 don't work I want to move on to another category

[jt07]

I never had much luck with the SNRIs because the norepinephrine component really made my anxiety go crazy.

[mikl_pls]

As for the SSRIs, Prozac and Zoloft were my favorites.

Maybe you'd have more luck with the SMSs (serotonin modulators and stimulators), Viibryd and Trintellix? I loved Viibryd while it worked for me.

As for the SNRIs, while Effexor worked the best, it had rapid poop out; however, when it comes to consistency of efficacy, Cymbalta was a great med for me. Fetzima was crap. Pristiq was also crap. YMMV.

 

[melissaw72]

3 hours ago, Geek said:

Some people find Wellbutrin activating also, it's a good thing to try too.

FWIW I find this very activating, but a great med to be on. YMMV.  I think it would be worth trying again

 

[Ion]

Thank you for all the comments. I'm going to read up on all the meds discussed and I've been making lots of notes for my next talk with my GP and my later appointment with my pdoc.

I've going to talk to my GP about what we can do before the pdoc appointment to finish answering if citalopram has any benefit. The pdoc appointment is at the end of May, so there's time to try more things with citalopram and really rule it in or out. I'm also going to bring up the possibility of getting physical tests done because they haven't been for 10 years and I think it may be helpful to rule that out as a contributing factor.

Then with the pdoc I think I would like to discuss trying another category as the next step. I'm currently most interested in Wellbutrin because it seems strong in a lot of areas related to my symptoms (low energy, poor concentration, oversleeping, overeating, and I have a low libedo but I'm not sure if that's caused by the depression for me). Not all of those are high priority symptoms for me, but I like that it might cover a lot of things. So that's where my thinking is going, but I'll see what the pdoc thinks/recommends and go from there.

[melissaw72]

35 minutes ago, Ion said:

I'm currently most interested in Wellbutrin because it seems strong in a lot of areas related to my symptoms (low energy, poor concentration, oversleeping, overeating,

These are the reasons I am on Wellbutrin.

[Iceberg]

The only thing I would caution you about is make sure your anxiety is under control 

[melissaw72]

25 minutes ago, Iceberg said:

The only thing I would caution you about is make sure your anxiety is under control 

Good point. 

[Ion]

11 minutes ago, Iceberg said:

The only thing I would caution you about is make sure your anxiety is under control 

I'm going to have to watch for that. The lifestyle things I do to manage my mental health help more for the anxiety than the depression, so the anxiety is overall in a better place, but it's still a factor I'm going to have to pay attention to

[Ion]

I had a great appointment with my GP. There was a record of blood work from more recently that I didn't remember, and it was all normal, so that's crossed off the list. We made a plan to max out the citalopram before I see the psychiatrist. She was really good about me wanting to be informed and involved, which is not a common trait in a lot of doctors I have seen.

I asked, and the pdoc won't be taking over prescribing. It's one consultation and then presumably they give advice to my GP and she and I continue to work together. So far, so good. Now to wait for the pdoc appointment

[melissaw72]

I'm glad your GP appt went well   I hope your pdoc appt goes well also!

[mcjimjam]

I would probably give the citalopram more time to work. It can take two months to work and if they increase the dose that may take that time again to see the additional benefit.

Often if the first AD fails they might try another SSRI or Wellbutrin which works in a different way. SSRIs in general can cause apathy, and I found citalopram/escitalopram worst for this. I didn't have this issue on Zoloft or Prozac.

Wellbutrin was more energising and stimulating for me and rather than apathy I think I cared about things more and felt more motivated. It can cause anxiety and insomnia for some but lacks the fatigue and sexual side effects of SSRIs.

 

As for Abilify, I haven't taken it but if citalopram is your first med, your doc might want to see if another one can manage your condition alone, with out an additional new. Abilify helps some people greatly but it does have risks, perhaps more so than most antidepressants.

[Iceberg]

Ehhh...really low dose abilify doesn't strike me as dangerous

One med is preferable but if you need two after a fair try on celexa maybe worth a talk...but I would try maybe some other ads first 

[Ion]

I had the appointment with the pdoc. He's mostly good to work with. He asked really good questions, but he seems to somewhat underestimate my symptoms because I work so hard to manage them. It is challenging for him to get a complete picture of my history in an hour, though. I'll have a follow-up with him in a month and until then he wants me to stay on the Citalopram. It's a completely reasonable plan, but I'm finding it a bit tough to be patient. Meds are a slow process.

I've been at 40mg on the Citalopram for a few weeks. As the dose had gone up the balance of positive and negative effects has shifted and it is now more positive than negative. I'm less generally apathetic and I do see some benefits from caring less about some things. It still only hits a few of my symptoms and not the top 2 that are most important to me.

[browri]

If you find the apathy intolerable at any point, it's very common to augment Celexa or Lexapro with Wellbutrin. If you find that your depression is more of a problem, then switch from Celexa 40mg to Lexapro 20mg. If you find that you're having issues with energy, motivation, or concentration, then add a bupropion product. My recommendation would be to take bupropion hydrobromide instead of bupropion hydrochloride. I felt that the bromide formulation (known as the brand name Aplenzin) made me feel less jittery and may be smarter for you if you do have issues with anxiety. Celexa will help curb some of the anxiety from Wellbutrin but taking brand name Aplenzin instead of generic Wellbutrin will be a good precautionary measure.

Bupropion can do wonders for anhedonia, but if you're looking for an SSRI to do it, Zoloft can be a safer bet. Zoloft and Prozac can both be stimulating but Zoloft has far more of an effect on dopamine like bupropion which makes it more suitable for severe melancholic depression.

It would be worth it to take an SSRI + bupropion before trying Abilify just because Abilify is an antipsychotic and can come with a slew of side effects that can oftentimes be less tolerable than antidepressants. YMMV though.

EDIT: @water takes Aplenzin as well and may be able to contribute her two cents here.

Edited June 1, 2017 by browri

[water]

On 6/1/2017 at 11:30 AM, browri said:

My recommendation would be to take bupropion hydrobromide instead of bupropion hydrochloride. I felt that the bromide formulation (known as the brand name Aplenzin) made me feel less jittery and may be smarter for you if you do have issues with anxiety. Celexa will help curb some of the anxiety from Wellbutrin but taking brand name Aplenzin instead of generic Wellbutrin will be a good precautionary measure.

yes yes yes yes!! I was hesitant to attribute this to the sodium bromide vs. hydrochloride, but except for the release method, Wellbutrin and Aplenzin are similar. I take the 522 mg. which is one pill and equivalent to the Wellbutrin 450XL which has to be taken in two pills.

My combo of bupropion and lexapro has been fantastic. Not changed at all since the beginning. **knocks on wood**

Another functioning depressive. you HAVE to tell the docs what is going on, otherwise they will think you are doing better than you are. Do not wait. Life is too short. Ask them to add in something. I would start with the smallest dose but use the XL, extended release method. When bupropion is dumped into the body all at once, it can cause major side effects. I went from IR to SR to XL. If I had to do it all again, I might have started with the 150 XL. Cut out all coffee at first, it is very jittery. 

Overall, the combo works great together. One med takes care of the other med. A perfect dish. 

[Ion]

I really appreciate all the comments and info. I'm brainstorming and making notes on what I need to communicate in my next pdoc appointment. I'll bring up Wellbutrin/bupropion if he doesn't.

[Ion]

My next appointment is in a week. No major change with the extra time on 40mg citalopram. It has a partial effect, but just isn't doing enough.

I want to discuss wellbutrin at the appointment, and I'm wary of making request since a number of Drs I've talked to before seem to dislike this. Are there more effective ways to bring it up? I tried search for existing threads, but didn't hit on the right search terms.

[jt07]

I would just bring up Wellbutrin whether your doctor likes it or not. It's not a controlled substance. Why suffer?

I've never had a psychiatrist who minded my making suggestions unless it was fior a controlled substance, 

[Ion]

My appointment went really well. We communicated much better this time and after we ran through the symptoms he suggested Wellbutrin before I could bring it up. Starting on 150mg XL

[mikl_pls]

That's good! Maybe next time, if you're tolerating it well, you can move up to the typical target dose of 300 mg, but if 150 mg is doing perfectly well for you, there's probably no reason to increase it I guess.

[browri]

Sometimes when you're using bupropion to augment and not as the main antidepressant you don't need to go any higher than 150mg. And like I said @Ion, if you get the jitters, ask for Aplenzin. There's a savings card that makes it like $5, and it doesn't antagonize anxiety as much.

[Ion]

4 hours ago, mikl_pls said:

That's good! Maybe next time, if you're tolerating it well, you can move up to the typical target dose of 300 mg, but if 150 mg is doing perfectly well for you, there's probably no reason to increase it I guess.

My pdoc seems like the cautious sort, but that works for me. He's told me that based on how long I've been depressed I can expect to be taking meds for at least 3 years. I think he might be trying to find the lowest effective dose.

3 minutes ago, browri said:

Sometimes when you're using bupropion to augment and not as the main antidepressant you don't need to go any higher than 150mg. And like I said @Ion, if you get the jitters, ask for Aplenzin. There's a savings card that makes it like $5, and it doesn't antagonize anxiety as much.

I'm keeping that in mind if the anxiety is an issue!

[mikl_pls]

6 hours ago, Ion said:

based on how long I've been depressed I can expect to be taking meds for at least 3 years.

I wouldn't be surprised if I had to be medicated my whole life.

6 hours ago, Ion said:

I think he might be trying to find the lowest effective dose.

Well, I can certainly see the good in that.

[Ion]

1 hour ago, mikl_pls said:

I wouldn't be surprised if I had to be medicated my whole life.

That's probably a possibility for me, too, but if I get a good response from the meds I would be happy to do so