Non-Traditional Options

[Geek]

Last week my pdoc said she wants to have me re-try Lexapro. After trying other meds, Lexapro helped me get through college in 2009-2012, but it stopped working and I came off it about six months after graduating. I tried Viibryd next, to no avail. Shortly after that my GP referred me to my pdoc who I've been with ever since.

The list of meds I've tried is in my signature and profile. It's long, and covers pretty much every class of traditional anti-depressants, various mood stabilizers and several AAPs. I've done TMS and ECT. I have ADHD so I take a stimulant (Vyvanse these days, though I've tried several including Strattera). I have insomnia so I take trazodone for sleep. I take an L-methylfolate supplement daily.

I fear my pdoc, in wanting to return to a med that helped (but not completely) but pooped out, is giving up.

Are there other non-traditional/off-label anti-depressants? In early summer pdoc tried me on Mirapex (no response). I've also tried buprenorphine (made me very ill).

Ketamine by IV was great, but the effects don't last. Ketamine shots (IM) don't seem to touch the depression. I've received both by participating in a medical study (testing to see if response to IV-ketamine could be maintained by IM-ketamine... not in me, it seems). I don't have the money to get ketamine infusions (which aren't covered by insurance).

Oh, and yes, I am in regular (weekly) talk therapy. I've done CBT and DBT based programs as well, group and individual settings.

 

[CeremonyNewOrder]

Hi Geek,

Sorry I can't see your signature because I'm on a phone so I can't see the meds you've tried. I am schizoaffective but I found that it took a combination of various class of psych meds before my depression went into remission. My combination is Clozapine, lithium, cymbalta, and Adderall.

[jt07]

@Geek The only cocktails that work for me always include an antidepressant + an anticonvulsant + an atypical antipsychotic. This was discovered when I was in the hospital because antidepressants alone do nothing for me. It took some good pdocs who were able to think outside the box.  Even though these meds are often used to treat bipolar disorder, I am unipolar.

Edit: A stimulant (Ritalin) helps me too.

Edited November 28, 2017 by jt07

[BrianOCD]

On 11/26/2017 at 4:20 PM, Geek said:

 

Ketamine by IV was great, but the effects don't last. Ketamine shots (IM) don't seem to touch the depression. I've received both by participating in a medical study (testing to see if response to IV-ketamine could be maintained by IM-ketamine... not in me, it seems). I don't have the money to get ketamine infusions (which aren't covered by insurance).

 

 

I'm curious to hear more about your Ketamine shots...My PDoc mentioned it to me as well, but I don't have insurance or the money to spend on that kind of thing...

What were the effects of the Ketamine?  No Mood boost at all?

[mikl_pls]

I'm so sorry you've gone through so much. It seems you and I have a lot in common. I really wanted to get ECT back in fall of 2016 but my pdoc failed to get anything set up about that. My pdoc doesn't do TMS, but does do VNS, and would've probably encouraged me to get a vagus nerve stimulator without trying ECT. I admit I'm jealous you got to try buprenorphine, ketamine, ECT, TMS, etc., but again, sorry they didn't work for you. I wish something had after all you've gone through.

It seems I've read somewhere (it seems I can never produce a link though when I say anything) that low-dose clozapine can help severely treatment-resistant depressed patients.

I read in a google book (no link available... sorry...) that the combination of nortriptyline and lithium during maintenance ECT was more likely to prevent relapse than just the two meds alone or maintenance ECT alone. You will definitely want to check with your pdoc about that "citation" though, especially since I can't provide the source.

Mirapex has the most research behind treating depression, but Requip has also been used, and apparently Neupro too (but Neupro $$$!!!), but I'm sure you're done with dopamine agonists by now.

Buspirone, at which doses specifically preferentially I don't know, supposedly has the ability to antagonize the dopamine autoreceptor, thereby inducing dopamine release. It's also a 5-HT_1A partial agonist, which would theoretically induce downstream dopamine release, though it's of a lower intrinsic activity than Viibryd or Trintellix, so if neither of those worked for you, that mechanism, at least, wouldn't work for you; however, the preferential dopamine autoreceptor antagonism might be worth looking into. There are meds outside of this country that do that in low doses, namely the antipsychotics amisulpride, sulpiride, and flupenthixol (or flupentixol, however you want to spell it), but it's a shame that we don't have these meds...

But I wish you the absolute best of luck in finding something that helps you out, and take care meantime!

[dancesintherain]

You’ve really been through the wringer.  I’m on my phone, so can’t read through your list...tagging now so I can hopefully remember to recheck when I’m on a computer.

 

though going back to something that worked (and admittedly stopped) may not be that strange—it’s the main reason I’m titrating up on lamictal.  We will see if that works.

[Geek]

Update, 5 months later...

Lexapro didn't help. I took up to 40mg from late November 2017 thru early February 2018, culminating in a 6-day IP stay at the beginning of February.

While IP, I was (abruptly) taken off of 40mg Lexapro and started on 100mg Pristiq. I saw my outpatient pdoc two days after discharge and she said to reduce the Pristiq to 50mg/day (due to no studies proving increased efficacy at 100mg/day) and said I could take some Lexapro to attenuate the discontinuation effects I was having. I tapered off the Lexapro over the course of about 2 weeks. She also added, temporarily, up to 0.5mg Xanax nightly because anxiety was keeping me awake. I had been prescribed 150-200mg/night of Trazodone for sleep and found that with Pristiq I had to take 200mg.

Pristiq seems to have had minimal to no benefit. My pdoc added Mirapex, quickly tapering up from 0.125mg/day to 0.75mg/day (taper was 0.125mg increase every 3-4 days). Upon reaching 0.75mg daily dose I started getting daily low-level headaches (3/10 pain level) and had 3 migraines within 6 days of the dose change (my previous most-recent migraine was 5-6 months prior). So pdoc had me stop that.

About 4 weeks ago, pdoc had me increase the Pristiq to 100mg. No benefits. Sleep is harder. I started having weird/vivid dreams (I don't usually dream). She suggested perhaps with the 200mg Traz I was getting too much serotonin so had me try reducing that to 150mg/night. That didn't change the dreams but did reduce the amount of sleep I was getting (I fall asleep okay, but have been waking up early). After a week, she said I could go back up to 200mg/night because lack of sleep is a big/quick trigger for my depression.

My depression ebbs and flows, always has. I am doing quite poorly at the moment, and am (again) not far from being sent IP, if I were honest with my care team. Last Friday I cried in my pdoc's office for the first time since February (I see her weekly). She said she was going to do a deep review of my chart and have a plan for when I see her tomorrow.

I know that two meds she's talked about before are Fetzima and Depakote. I'm not excited about weight gain from Depakote. Given how Pristiq is (not) working, another SNRI like Fetzima seems like a long shot.

I'm feeling pretty hopeless and out of options.

[Iceberg]

Fetzima has a unique ratio of serotonin to norepinephrine effect so it's possible that u *might* get a different effect. I've heard very mixed reviews about fetzima tho

Unfortunately, Depakote didn't do shit for my depression

[HydroCat]

Fetzima is Levomilnacipran. I've been on Milnacipran. It has more effect on norepinephrine reuptake than on serotonin, so if SSRI/Pristiq didn't work for you this one might.

In my experience it is very activating and gives a great energy and motivation boost if that is what you need.

Have you tried augmentation to SSRI? A low dose AAP may make the difference. After Prozac (SSRI) was too weak for me, my pdoc added a sub-minimal dose of Risperidone (AAP) with good results... and it is not bad for sleep either.

edit:

Just saw you said that you have tried AAPs on the first post. with or without antidepressant?

Edited May 4, 2018 by HydroCat

[Geek]

53 minutes ago, HydroCat said:

Fetzima is Levomilnacipran. I've been on Milnacipran. It has more effect on norepinephrine reuptake than on serotonin, so if SSRI/Pristiq didn't work for you this one might.

In my experience it is very activating and gives a great energy and motivation boost if that is what you need.

Have you tried augmentation to SSRI? A low dose AAP may make the difference. After Prozac (SSRI) was too weak for me, my pdoc added a sub-minimal dose of Risperidone (AAP) with good results... and it is not bad for sleep either.

edit:

Just saw you said that you have tried AAPs on the first post. with or without antidepressant?

From AAPs, I have tried Abilify, Rexulti and Vraylar - always with an antidepressant, though apparently not an SSRI specifically. I took Abilify in combination with Parnate (MAOI) (as well as, simultaneously, Lithium, Lamictal and Ritalin - making @jt07's magic formula). I took Rexulti with Trintellix and later Imipramine (a tricyclic), and simultaneously with Vyvanse. I took Vraylar while also taking Remeron (and Vyvanse). 

I augmented EffexorXR (SNRI) with Lamictal prior to washing out and trying Parnate.

When I took Lexapro this winter, and when I switched to Pristiq in February, I was not augmenting either with an AAP. Trazodone (for sleep, no more than 200mg) and Vyvanse. 

Other SSRIs I've tried (Paxil and Zoloft) didn't agree with me. Wellbutrin was too stimulating and had no benefits. Mirapex made me ill, as did Buprenorphine. I took Strattera for a while, with Lexapro (many years ago) and more recently with Imipramine. It was less effective than stimulants. I prefer amphetamines to methylphenidates.

---

I saw pdoc today. She wants to try Nardil (an MAOI), because I had a better response to Parnate than any other AD (until it pooped out or something) and she thinks Nardil is worth a shot because I have pretty anxious depression. I'm to taper quite quickly off of the Pristiq (100mg every other day for 3 doses, then nothing). She's also introducing Abilify (2.5mg for two nights, then up to 5mg on-going) to help "bridge" the washout. She did that when I took Parnate too, and I stayed on Abilify for almost 2 years.

I am not looking forward to taking an MAOI again. The diet and drug restrictions, regularly taking my blood pressure, no Vyvanse (or even Ritalin derivatives, at least initially)... *sigh* On the other hand, the other thing that had much benefit was ECT (but I can't work while getting it frequently enough to be beneficial).