Increasing Zoloft / sertraline to 200 mg

[Catwoman]

I convinced my gdoc this morning to increase my dose of Zoloft from 150 to 200 mg.
I'm already taking 175 mg actually. With each increase the RLS (restless legs, or feet and ankles in my case) gets worse. I'm supplementing with iron and it seems to help a little. Some one suggested magnesium as well, but this person doesn't know I'm on medication, so I don't know if magnesium will actually work for SSRI-induced restless legs.

Other than de RLS I don't experience much from the Zoloft. I think it's working partially because in some situations these thoughts aren't as frequent and I can concentrate better. Especially when I'm around people, have important things to do. When my attention turns outwards, so to say.

From the beginning of February I do have a lot on my mind. There's a situation going on in my life which is giving me stress and anxiety. It's a big thing in my life right now which could end rather sad. I'll have to wait and can't do much about the situation. To relax and let go I've started running again and listen to audio books a (it's almost therapy, I love listening to novels and it's incredibly useful when I can't sleep right away).

The intrusive thoughts are more frequent when I'm going through these kind of stressful events in life. I don't think the Zoloft is able to help with the intrusive thoughts at the moment. Maybe it will kick in when it's all over. I decided to give the 200 mg a try for about  a month.

My pdoc advised Anafranil (clomipramine) but I'm not sure because of the effects on histamine, muscarine and cholinergic receptors. I could handle dry mouth and constipation, but gaining weight and dizziness is something I really need to avoid!

I wonder if going back to Luvox will do the trick or if trying Prozac is an option. They are both SSRI's and Luvox and Lexapro worked incredibly good for me. Zoloft just doesn't and I still don't get that. Pulling out the big guns like Anafranil feels a bit extreme?
 

Edited April 5, 2017 by Catwoman

[mikl_pls]

Between the ones you mentioned switching to from sertraline, Luvox seems to be the most promising because of its potent σ receptor binding properties (which Zoloft shares but not as robustly). Prozac is also said to be a ligand of this receptor, but I don't know where it falls between Zoloft and Luvox. Before you call it quits on the Luvox, make sure you give it a try at the max dose (300 mg).

Another possibility is, instead of switching completely over to Anafranil, is adding a small supplemental dose of it to your current antidepressant. I've read that's something that some people's pdocs do, and it seems to help.

But Anafranil itself I don't think would be that bad (don't know myself though as I've never taken it). Weight gain I've heard is minimal with this one.

Good luck with whatever you decide to do, and I hope it works for you!

[CrazyRedhead]

1 hour ago, Catwoman said:

 My pdoc advised Anafranil (clomipramine) but I'm not sure because of the effects on histamine, muscarine and cholinergic receptors. I could handle dry mouth and constipation, but gaining weight and dizziness is something I really need to avoid!

I take Anafranil and haven't experienced any weight gain or dizziness.....

The only side effect I have had with it, is a mild case of dry mouth, which went away after a few months of starting it.

[Catwoman]

On 5-4-2017 at 1:36 PM, CrazyRedhead said:

I take Anafranil and haven't experienced any weight gain or dizziness.....

The only side effect I have had with it, is a mild case of dry mouth, which went away after a few months of starting it.

Good to hear! Did drinking more water help with the dry mouth? Of chewing (sugar free) gum?
I've never gained noticable weight on any SSRI's, but since Anafranil is a stronger antidepressant I thought I might have a bigger chance of gaining weight on it. 
 

 

On 5-4-2017 at 0:59 PM, mikl_pls said:

Between the ones you mentioned switching to from sertraline, Luvox seems to be the most promising because of its potent σ receptor binding properties (which Zoloft shares but not as robustly). Prozac is also said to be a ligand of this receptor, but I don't know where it falls between Zoloft and Luvox. Before you call it quits on the Luvox, make sure you give it a try at the max dose (300 mg).

Another possibility is, instead of switching completely over to Anafranil, is adding a small supplemental dose of it to your current antidepressant. I've read that's something that some people's pdocs do, and it seems to help.

But Anafranil itself I don't think would be that bad (don't know myself though as I've never taken it). Weight gain I've heard is minimal with this one.

Good luck with whatever you decide to do, and I hope it works for you!

Thanks Mik!

I always assumed that once a SSRI stops working you'll need to switch over to another SSRI, to another class or take a long drug holiday.
It's been 7 years since I stopped Luvox, but in the mean time I took Lexapro, so I have no idea what my chances with Luvox are.

I assumed Zoloft would be just as effective because it is an SSRI, it has more affinity for the dopamine receptors and it binds to the  σ receptors (though not as strong as Luvox does).
Luvox worked incredibly for me. The intrusive thoughts (which I had for 4 years already) vanished with 9 weeks on Luvox. 

I would rather stay in the SSRI class because I know after 10 years of being on them I don't experience much side effects.
TCA's are an unknown class for me....though they are reuptake inhibitors, they still scare me.
On the other hand I don't look forward to trying out Prozac, Luvox, Paxil and Celexa, then go on Anafranil and come to the conclusion that I should have done that instead of trying all the SSRI's ;-)

 

Edited April 7, 2017 by Catwoman

[CrazyRedhead]

On 4/7/2017 at 4:36 AM, Catwoman said:

Good to hear! Did drinking more water help with the dry mouth? Of chewing (sugar free) gum?
I've never gained noticable weight on any SSRI's, but since Anafranil is a stronger antidepressant I thought I might have a bigger chance of gaining weight on it. 

Yes, I chewed gum, and it did help.....But, like I said, it was very mild, and I hardly noticed it.

Some people, from what I've seen, do gain weight on SSRIs, so you're fortunate that it didn't happen to you.......For instance, my sister has been on Celexa for a few years, and has gained about 30 lbs on it, but it really helps her a lot, so she decided to stay with it.

When I tried Paxil, I gained about 20 pounds on it, but it didn't really help me, and after I stopped it, the weight came off easily...So SSRIs do cause weight gain in some people.

 Anafranil does have the potential chance for weight gain, but not huge weight gain, and it doesn't happen to everybody........It didn't happen for me, anyway.......The only way for you to find out is try it.........Everyone's different.

Edited April 10, 2017 by CrazyRedhead

[Catwoman]

Hey guys, 

Short update and a few questions that have been bugging me.

It seems like the sertraline has kicked in with 200 mg. I've been on it for about a month.
Side effects are still tolerable. RLS in the morning but my sleep is fine, some muscle twitches and tinnitus when I'm going to bed. 

I'm at a high dose and it's the same as with the other SSRI's: side effects aren't that bad. I don't notice much during the day. I consider it a lucky thing, but I'm curious as to why this is. 
Am I a fast metabolizer? Read something about a certain enzyme, but I'm not that smart ;-)

I'm not sure if I will stay on Zoloft. It was doing the trick for a few weeks, but lately the intrusive thought is far more frequent.  That's a bit dissapointing, but it happened to me with Lexapro as well.
At the moment I'm  dealing with a lot of stress and anxiety due to issues and health problems in my family.  I don't know how to explain this in English exactly, but maybe the Zoloft isn't strong enough right now. I can always switch to another med, OR I could wait out these issues. 
Any thoughts on this?

[browri]

@Catwoman I have a serious problem with racing intrusive thoughts and general mental pressure when I'm about to enter a manic episode. I've tried anticonvulsants, different antidepressants, but the only thing that has ever knocked them out is antipsychotics. Low doses though. Low doses are important. Find something with a really wide dosing schedule and start low and slow. Your pdoc will know what to do there. Antipsychotics can have some worrisome side effects, but as long as you take small doses, you can hopefully mitigate some of that risk.

[Catwoman]

10 hours ago, browri said:

@Catwoman I have a serious problem with racing intrusive thoughts and general mental pressure when I'm about to enter a manic episode. I've tried anticonvulsants, different antidepressants, but the only thing that has ever knocked them out is antipsychotics. Low doses though. Low doses are important. Find something with a really wide dosing schedule and start low and slow. Your pdoc will know what to do there. Antipsychotics can have some worrisome side effects, but as long as you take small doses, you can hopefully mitigate some of that risk.

Hey Browri, thanks for your feedback!

I still haven't had any succes in finding a pdoc just to consult for medication issues. I found one last January but I couldn't have a follow up consultation and the others have waiting lists or want me back in therapy. I have no other problems than the recurring thought in head and I've been in therapy since I was 19....And I still see my psychologist....

My general doc isn't supporting me in taking these kinds of meds (and still thinks I have a better chance with mindfulness meditation), but he does prescribe me the 'usual' stuff like SSRI's or TCA's, because he has experience with these. My previous pdoc has advised me quetiapine, so my general doc with probably listen to him instead of me suggesting Abilify. Doctors don't like patients who have done their own research and want to talk about suggestions from people on forums (though I think these people know a lot more about psych meds than most general doctors).  

I feel really demotivated lately and sometimes even lethargic in the mornings. People say I just have to give myself a kick under the butt...
I think Abilify wouldn't be that bad, but on the other hand, Zoloft's affinity for dopamine is noticable at 200 mg.

Edited May 11, 2017 by Catwoman

[browri]

@Catwoman Do you take Zoloft at night or in the morning? It's pretty activating and is generally better suited as a morning med. If you're having issues with motivation and feeling lethargic in the mornings then Seroquel may not be the best place to start. You're better off with Abilify which is oftentimes more stimulating and should help with energy/motivational issues.

[Catwoman]

1 hour ago, browri said:

@Catwoman Do you take Zoloft at night or in the morning? It's pretty activating and is generally better suited as a morning med. If you're having issues with motivation and feeling lethargic in the mornings then Seroquel may not be the best place to start. You're better off with Abilify which is oftentimes more stimulating and should help with energy/motivational issues.

I was worried about insomnia so I started out with taking it in the morning, but in 4 months I just had one sleepless night.
When I take them before bed I feel the same as when I take them in the morning and no difference in motivation, but my esophagus gets irritated if I don't take the tablets with enough water.  So that would be a good reason to take them in the morning. 

I still wonder why I did so well on Luvox ;-)

[browri]

4 hours ago, Catwoman said:

I was worried about insomnia so I started out with taking it in the morning, but in 4 months I just had one sleepless night.
When I take them before bed I feel the same as when I take them in the morning and no difference in motivation, but my esophagus gets irritated if I don't take the tablets with enough water.  So that would be a good reason to take them in the morning. 

I still wonder why I did so well on Luvox ;-)

Well if your issue was intrusive compulsive thoughts, Luvox would make sense. But I find mine well-controlled with my combination. Specifically the Oxtellar and the loxapine.

[Catwoman]

8 hours ago, browri said:

Well if your issue was intrusive compulsive thoughts, Luvox would make sense. But I find mine well-controlled with my combination. Specifically the Oxtellar and the loxapine.

It was my first anti-depressant and I liked it because side effects were so mild (RLS only) and it just got rid of the intrusive thought completely. It didn't even need the highest dose. After 7 months or something I went off it, went on it again when the intrusive thoughts suddenly came back.  The second time it worked as well and I was in complete remission again. I decided to taper but after a few med-free months the thought came back. I panicked and started the Luvox again. After 9 weeks of going up and down I asked my doctor to switch to something else. It seemed like it gradually pooped-out.

My last time on Luvox was about 7 years ago, so I have no idea if I could take a gamble and cross taper to Luvox if Zoloft doesn't work out.
Their receptor binding profile isn't as different as I recall correctly.
 

Edited May 12, 2017 by Catwoman

[browri]

17 hours ago, Catwoman said:

It was my first anti-depressant and I liked it because side effects were so mild (RLS only) and it just got rid of the intrusive thought completely. It didn't even need the highest dose. After 7 months or something I went off it, went on it again when the intrusive thoughts suddenly came back.  The second time it worked as well and I was in complete remission again. I decided to taper but after a few med-free months the thought came back. I panicked and started the Luvox again. After 9 weeks of going up and down I asked my doctor to switch to something else. It seemed like it gradually pooped-out.

My last time on Luvox was about 7 years ago, so I have no idea if I could take a gamble and cross taper to Luvox if Zoloft doesn't work out.
Their receptor binding profile isn't as different as I recall correctly.
 

If it's worked for you in the past, its always worth another trial, especially after so long a period of time. Alternatively, have you ever tried some plain ole Prozac?

[Catwoman]

On 2017-5-13 at 2:49 AM, browri said:

If it's worked for you in the past, its always worth another trial, especially after so long a period of time. Alternatively, have you ever tried some plain ole Prozac?

Apparantly there are differences between Luvox and Zoloft and there must be a reason why Luvox worked so much better. 
Of course I'm going through a lot of stressfull period, so I'll give Zoloft a try for a few more weeks.
I've been on it from last January and I'm still not where I am supposed to be concerning medication results. 

No, I've never been on Prozac, so I'll think I'll ask my gdoc about Prozac, Luvox and Anafranil and skip the antipsychotic route for now.
Good idea?

[browri]

4 hours ago, Catwoman said:

Apparantly there are differences between Luvox and Zoloft and there must be a reason why Luvox worked so much better. 
Of course I'm going through a lot of stressfull period, so I'll give Zoloft a try for a few more weeks.
I've been on it from last January and I'm still not where I am supposed to be concerning medication results. 

No, I've never been on Prozac, so I'll think I'll ask my gdoc about Prozac, Luvox and Anafranil and skip the antipsychotic route for now.
Good idea?

One thing that is unique about Luvox is that it is a fairly potent sigma receptor agonist. Zoloft and Prozac are both as well although to a lesser degree. I have a problem with intrusive, compulsive thoughts and other than Lexapro, that kind of anxiety has only responded to Prozac for me so far.

[Catwoman]

Lexapro was great for me, it worked after only three weeks and side effects were manageble. 
The difference with Luvox was that Luvox was working constantly over a longer period of time.  My journey with Lexapro was bumpy the first few months and it took like a year before it seemed to eliminate that intrusive thought completely.
Maybe the action on the sigma receptors is important in my case? Though Lexapro doesn't have any affinity for these receptors....

Aaaaargh I don't know!!!  

[browri]

6 minutes ago, Catwoman said:

Lexapro was great for me, it worked after only three weeks and side effects were manageble. 
The difference with Luvox was that Luvox was working constantly over a longer period of time.  My journey with Lexapro was bumpy the first few months and it took like a year before it seemed to eliminate that intrusive thought completely.
Maybe the action on the sigma receptors is important in my case? Though Lexapro doesn't have any affinity for these receptors....

Aaaaargh I don't know!!!  

I actually found ONE fabulous study that lists the SSRIs tested in order by potency to the sigma 1 receptor:

https://www.ncbi.nlm.nih.gov/pubmed/24508523

fluvoxamine>sertraline>fluoxetine>escitalopram>citalopram>paroxetine>duloxetine.

So in this case if Zoloft doesn't work and you do want to keep trying new medications instead of going back to something that might not work anymore (Luvox), Prozac would be your next logical try. Sigma receptors have been implicated in anxiety and panic. It could be integral to your treatment depending on how your brain works. I know it's a woefully overused phrase by YMMV

Edited May 16, 2017 by browri

[Catwoman]

21 hours ago, browri said:

I actually found ONE fabulous study that lists the SSRIs tested in order by potency to the sigma 1 receptor:

https://www.ncbi.nlm.nih.gov/pubmed/24508523

fluvoxamine>sertraline>fluoxetine>escitalopram>citalopram>paroxetine>duloxetine.

So in this case if Zoloft doesn't work and you do want to keep trying new medications instead of going back to something that might not work anymore (Luvox), Prozac would be your next logical try. Sigma receptors have been implicated in anxiety and panic. It could be integral to your treatment depending on how your brain works. I know it's a woefully overused phrase by YMMV

Thanks Browri, that ís interesting indeed!

I was looking at the Wikipedia section on sigma receptors and read that fluvoxamine is an agonist and sertraline an antagonist. 

And from that article on Pubmed:
" These findings suggest that activation at the sigma-1 receptor chaperone may be involved in the action of some SSRIs, such as fluvoxamine, fluoxetine and escitalopram."

Escitalopram en fluvoxamine actually worked for me, where sertraline really doesn't and I've been on it for 5 months now! Maybe these sigma receptors are involved in this some how...

[browri]

On 5/17/2017 at 5:34 AM, Catwoman said:

Thanks Browri, that ís interesting indeed!

I was looking at the Wikipedia section on sigma receptors and read that fluvoxamine is an agonist and sertraline an antagonist. 

And from that article on Pubmed:
" These findings suggest that activation at the sigma-1 receptor chaperone may be involved in the action of some SSRIs, such as fluvoxamine, fluoxetine and escitalopram."

Escitalopram en fluvoxamine actually worked for me, where sertraline really doesn't and I've been on it for 5 months now! Maybe these sigma receptors are involved in this some how...

It would seem that if Zoloft doesn't work out Prozac might be your next best bet.

[Catwoman]

16 hours ago, browri said:

It would seem that if Zoloft doesn't work out Prozac might be your next best bet.

It's worth a try. It can't be much worse than being on Zoloft for 5 months without much progress.

I'll probably need taper from Zoloft to like 150 or 100 mg and then cross taper with Prozac?


I also noticed that Luvox has a lower Ki (nM) value for NET / norepinephine transporter than Prozac (660) and Zoloft (925).
Luvox's Ki value is 1,119. The lower the value, the higher the potency  if I understand correctly.
I wonder what the role of norephinephrine is in my case. Luvox was the best out of the three. I have no compulsions at all (I just have one intrusive thought which doesn't go away) but I'm not sure if I would like Effexor or Cymbalta so I'll think I'll try Prozac or Luvox first....
 

Edited May 19, 2017 by Catwoman

[browri]

5 hours ago, Catwoman said:

It's worth a try. It can't be much worse than being on Zoloft for 5 months without much progress.

I'll probably need taper from Zoloft to like 150 or 100 mg and then cross taper with Prozac?


I also noticed that Luvox has a lower Ki (nM) value for NET / norepinephine transporter than Prozac (660) and Zoloft (925).
Luvox's Ki value is 1,119. The lower the value, the higher the potency  if I understand correctly.
I wonder what the role of norephinephrine is in my case. Luvox was the best out of the three. I have no compulsions at all (I just have one intrusive thought which doesn't go away) but I'm not sure if I would like Effexor or Cymbalta so I'll think I'll try Prozac or Luvox first....
 

The effects on norepinephrine can have positive effects on anxiety and attention as well as motivation and vigilance. But despite how little we know about it, the sigma receptor theory still seems to make more sense to me. You are correct about the Ki value. The lower the number, the higher the affinity it has for that receptor.

If this were me, and I stress that heavily because your doctor may want to do otherwise, I would drop Zoloft from 150mg to 100mg and immediately add 20mg of Prozac. I would take that for Week 1. Then I would drop the Zoloft down to 50mg and do that and 20mg of Prozac for Week 2. Then for Week 3 I would either drop down to 25mg or eliminate the Zoloft completely depending on how I feel. I have learned to wait until Week 4 before I decide if I need to go up to 40mg of Prozac. But it is important here to cross-titrate because it will take a long time to build up the blood levels of Prozac.

Effexor and Cymbalta are good for generalized anxiety disorder but I don't think they have an indication for OCD the way that several of the SSRIs do. My only caution with Luvox is that it messes with liver enzymes so make sure you check any other medications that you are prescribed to take with it to ensure they don't interact.

 

[Catwoman]

I'm putting off a new appointment with my general doctor. Probably because I still have a 2 week supply of Zoloft left and I still hope deep inside that Zoloft will kick in.

A few days ago I dropped from 250 to 200 mg. I'm sure they won't recommend this on the Surviving Antidepressant forums, but I've never experienced severe SSRI withdrawal symptoms.
I remember coming off Lexapro (I went slow, but faster then they advised me) and the only problems I had were ringing ears and cortisol spikes. I went off Luvox twice without even tapering. Side effects from all SSRI's are quite mild for me too, so I'm not worried about Zoloft tapering. Won't go off cold turkey off course, but I don't think I need to stay on dosages for more than one week, especially when I'm cross tapering / titrating.

No I don't think Cymbalta is used often for OCD, but I know Effexor is. I wonder about side effects from that one; I know it mainly effects serotonin at lower dosages. But it's also famous for the brainzaps when titrating or tapering.
Not really looking forward to that....

This article http://www.psychotropical.com/clomipramine-potent-snri-anti-depressant is an interesting read on clomipramine. 
I'll think I'll keep that one as a second choice.

[mikl_pls]

Apparently, they've used up to 400 mg sertraline before in treatment-refractory patients.
https://www.ncbi.nlm.nih.gov/pubmed/16426083

[browri]

@Catwoman I actually have an idea that you might be interested in. And @mikl_pls check my work on this one because I know I can count on you

Clomipramine and fluvoxamine may both be the answer here if you're finding that anxiety and OCD-like symptoms are difficult to treat along with your depression:

https://www.ncbi.nlm.nih.gov/pubmed/8666564

Clomipramine (as a molecule hereby referred to as CMI) is extensively metabolized by CYP1A2 to desmethylclomipramine (DCMI). While CMI is a strong serotonin reuptake inhibiter, DCMI is mostly a norepinephrine reuptake inhibitor. CMI has a shorter half-life ranging from 19 to 37 hours while DCMI ranges from 54 to 77. This means clomipramine as a whole at steady state has a higher affinity for the norepinephrine transporter.

Luvox happens to be a strong CYP1A2 inhibitor (as well as an SSRI of course) and by taking it with clomipramine, you can increase the levels of CMI in your system and this fluvoxamine/clomipramine combination would be a much stronger serotonin reuptake inhibitor combined with the potency of fluvoxamine's sigma receptor properties.

In fact, Stephen Stahl goes into this combination in some detail in his Essential Psychpharmacology PDR.

Thoughts?

[Savannah]

There are many books by Stahl including several that say "Essential Psychopharmacology ".

 

which o you recommend?

[mikl_pls]

6 hours ago, browri said:

@Catwoman I actually have an idea that you might be interested in. And @mikl_pls check my work on this one because I know I can count on you

Clomipramine and fluvoxamine may both be the answer here if you're finding that anxiety and OCD-like symptoms are difficult to treat along with your depression:

https://www.ncbi.nlm.nih.gov/pubmed/8666564

Clomipramine (as a molecule hereby referred to as CMI) is extensively metabolized by CYP1A2 to desmethylclomipramine (DCMI). While CMI is a strong serotonin reuptake inhibiter, DCMI is mostly a norepinephrine reuptake inhibitor. CMI has a shorter half-life ranging from 19 to 37 hours while DCMI ranges from 54 to 77. This means clomipramine as a whole at steady state has a higher affinity for the norepinephrine transporter.

Luvox happens to be a strong CYP1A2 inhibitor (as well as an SSRI of course) and by taking it with clomipramine, you can increase the levels of CMI in your system and this fluvoxamine/clomipramine combination would be a much stronger serotonin reuptake inhibitor combined with the potency of fluvoxamine's sigma receptor properties.

In fact, Stephen Stahl goes into this combination in some detail in his Essential Psychpharmacology PDR.

Thoughts?

Great article! The only thing I foresee is increased levels of clomipramine from coadministration with fluvoxamine, so low doses of clomipramine would need to be used, and probably even routine blood work to monitor the levels of clomipramine to make sure they're within therapeutic range and not in toxic range.

[Catwoman]

17 hours ago, mikl_pls said:

Apparently, they've used up to 400 mg sertraline before in treatment-refractory patients.
https://www.ncbi.nlm.nih.gov/pubmed/16426083

Yes, I found that article earlier. I've been on 250 mg for about two weeks, but it seemed to make my intrusive thought(s) more frequent....Not sure if 400 mg does the trick when 20 mg of ecitalopram and 200 mg of fluvoxamine did...
I think I could handle 400 mg (though I should not take it before bed, because it irritates my stomach and esophagus) but I don't think my doctor would approve.

I wonder about the role of those sigma recepters, since sertraline is an antagonist and fluvoxamine and fluoxetine are angonists at that site.

Edited May 25, 2017 by Catwoman

[Catwoman]

7 hours ago, mikl_pls said:

Great article! The only thing I foresee is increased levels of clomipramine from coadministration with fluvoxamine, so low doses of clomipramine would need to be used, and probably even routine blood work to monitor the levels of clomipramine to make sure they're within therapeutic range and not in toxic range.

I found a Dutch article on that combo:

http://www.dejongepsychiater.nl/onderzoek/842-fluvoxamine-clomipramine-ocd-depressie

Maybe Google Translate will work. The writers of the article aren't quite sure if there's enough clinical evidence of the addition of clomipramine to fluvoxamine.
But they do think it can be useful for refractory OCD....

[mikl_pls]

3 hours ago, Catwoman said:

I found a Dutch article on that combo:

http://www.dejongepsychiater.nl/onderzoek/842-fluvoxamine-clomipramine-ocd-depressie

Maybe Google Translate will work. The writers of the article aren't quite sure if there's enough clinical evidence of the addition of clomipramine to fluvoxamine.
But they do think it can be useful for refractory OCD....

Makes me wonder what the difference between combining clomipramine and fluvoxamine and just administering supratherapeutic doses of fluvoxamine is (> 300 mg/day).

As for the interaction between CYP1A2, luckily most of the population are rapid CYP1A2 metabolizers.

[mikl_pls]

Have you tried any antiglutamatergic drugs?

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4425334/

http://www.medscape.org/viewarticle/778119_8

Lamotrigine, topiramate, zonisamide, memantine, amantadine, pregabalin, riluzole, N-acetylcysteine, stimulants, lithium, etc.

[browri]

17 hours ago, Savannah said:

There are many books by Stahl including several that say "Essential Psychopharmacology ".

 

which o you recommend?

The one I have is the 5th Edition of his Prescriber's Guide, but the 6th Edition just came out. I've gotta get it.

[Catwoman]

19 hours ago, mikl_pls said:

Have you tried any antiglutamatergic drugs?

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4425334/

http://www.medscape.org/viewarticle/778119_8

Lamotrigine, topiramate, zonisamide, memantine, amantadine, pregabalin, riluzole, N-acetylcysteine, stimulants, lithium, etc.

Yes and no....
I asked for memantine when I saw the pdoc in January but he said it was too experimental and too expensive. He said I should ttry the usual treatments and since I've already been on SSRI's he said I should try clomipramine or even adding quetiapine  to sertraline (which I don't want to take because it mostly blocks histamine). I did try NAC at high dosages (I wasn't on sertraline at that moment) and for a few weeks it seemed to help with the intrusive thought, but when I started the new bottle I didn't feel anything from it anymore. I'm not sure yet if the glumamatergic route is for me...

Edited May 26, 2017 by Catwoman

[browri]

Looking at your signature and the conversation we've had thus far, I still think an antipsychotic would do you good. intrusive thoughts aren't really helped well with SSRIs and they can even make it worse if it isn't under control. Luvox and loxapine would be a good combo as would clomipramine and loxapine. Saphris did a really good job of quieting my thoughts taking just 2.5mg at night and not twice daily like the dosing suggests. Olanzapine also did a good job at quieting my thoughts but the metabolic side effects aren't worth the trial in my mind.

[Catwoman]

I had an appointment with my psychologist today (been seeing her for a year now) I also did my mindfulness meditation course with her. I have one session left, but she's willing to refer me to a psychiatrist.  She actually thought it would be much more helpful for me to have a pdoc to discuss medication once in a while instead of going through more therapy.

The thing is: I'm not looking forward to be put on a waitinglist, then sit in a doc's waiting room for hours, explain the full story and then he/she will offer Seroquel or Risperdal. That's not what I want. I want go over the various options and I rather do this on the phone or by e-mail (which is more time efficient).  Some doctors may not like patients who read about pharmacology and some may think I'm a know-all, but I just want to talk more indepth and come up with a treatment that is not 'general'. 

Oh well, I'm going back to my general doctor and maybe I'll them him this. I'm leaning towards Prozac and I think he's willing to let me go on it.

What worries me the most about trying another SSRI is that I'm afraid my brain is now adapted to medication like this and not sensitive to the method of action. 
I'm actually really scared that nothing else will work because I've been on Lexapro so long and this med altered something permanently.....