Which antidepressant should I add?

[Catwoman]

I'm tapering off clomipramine, right now I'm down to 75 mg.
 

I've been on it for almost a year, but I'm not impressed with the results. I was hoping it would work better than my last two SSRI's (which seemed to do the best job when I took them for the first time) but I can't go higher than 100 mg because of side effects.

A few months ago risperidone was added to the clomipramine. I'm on 1 mg a day. I've seen some improvement, but I can still have difficult days or even weeks where I'm having too much intrusive thoughts (or thought, since it's been only one thought which bothers me). 

I've had good results from fluvoxamine and escitalopram, but both pooped out. Maybe clomipramine had pooped out too.

According to my pdoc, taking risperidone as a monotherapy won't have much effect. And with OCD, an antipsychotic is mainly added as an augment treatment.

So what to do next?

Edited June 17, 2019 by Catwoman

[Iceberg]

Well I guess Zoloft and Paxil would still be on the table but that’s if you want to go back to SSRIs. How high did you get on the other ones? 

[Catwoman]

1 hour ago, Iceberg said:

Well I guess Zoloft and Paxil would still be on the table but that’s if you want to go back to SSRIs. How high did you get on the other ones? 

Zoloft/Sertraline didn't work at all for me.
Tried it for about 9 months in various doses, and went as high as 250 mg. Gave me tinnitus at 200 mg, which I took for some months.

I liked Lexapro/escitalopram, which I took for 6 years, at the highest I was on 20 mg.
With Luvox / Fluvoxamine I don't remember...I definitely took 200 mg, but I think I would be able to take more.

I find Paxil kinda interesting, because paroxetine is the most potent and one of the most specific selective serotonin reuptake inhibitors, according to Wikipedia.

The point is....three SSRI's failed to work in the last three years....so that's why I went on clomipramine. 
 

[mikl_pls]

Paroxetine actually is significantly anticholinergic and becomes an NRI at higher doses. While paroxetine is one of the most potent, the most selective is escitalopram.

You could try ultra-high dose SSRIs. For example, if you liked escitalopram, you could go as high as 40 mg (some people do that). There was someone who was on I think 60 mg who was either on here or crazymeds, can't remember which. The thing you have to watch out for with that medicine is QT interval prolongation.

Fluvoxamine can be taken up to 400 mg I think in extenuating circumstances.

But there's always paroxetine. (I don't have any experience with that med as I've never taken it, but it is indicated for OCD in the US.) It comes in a CR (controlled release) version as well as instant release version.

As augmentative agents, there is always lamotrigine, memantine, and topiramate if your pdoc is open to them.

[CrazyRedhead]

2 hours ago, Catwoman said:

I liked Lexapro/escitalopram, which I took for 6 years, at the highest I was on 20 mg. 

Like @mikl_pls mentioned above,  you could increase the Lexapro dose you were taking.......For SSRIs at least, you usually need higher doses for OCD.........I take 30mg Lexapro......I did have to get a PA for that, since the max dose is supposed to be 20mg, but it was approved no problems from my insurance.

Edited June 17, 2019 by CrazyRedhead

[Iceberg]

22 minutes ago, CrazyRedhead said:

Like @mikl_pls mentioned above,  you could increase the Lexapro dose you were taking.......For SSRIs at least, you usually need higher doses for OCD.........I take 30mg Lexapro......I did have to get a PA for that, since the max dose is supposed to be 20mg, but it was approved no problems from my insurance.

That was my idea too- try 30 on the Lexapro... but I’m somewhat limited in SSRI experience so I wasn’t brave enough to suggest it til someone else brought it up. For what it’s worth- my Pdoc said he used to have people on 30mg all the time, and still does but I think less frequently cuz of annoying insurance 

[Catwoman]

1 hour ago, mikl_pls said:

Paroxetine actually is significantly anticholinergic and becomes an NRI at higher doses. While paroxetine is one of the most potent, the most selective is escitalopram.

You could try ultra-high dose SSRIs. For example, if you liked escitalopram, you could go as high as 40 mg (some people do that). There was someone who was on I think 60 mg who was either on here or crazymeds, can't remember which. The thing you have to watch out for with that medicine is QT interval prolongation.

Fluvoxamine can be taken up to 400 mg I think in extenuating circumstances.

But there's always paroxetine. (I don't have any experience with that med as I've never taken it, but it is indicated for OCD in the US.) It comes in a CR (controlled release) version as well as instant release version.

As augmentative agents, there is always lamotrigine, memantine, and topiramate if your pdoc is open to them.

Thanks!

So 'selective' is better than 'potent'?

I've been off escitalopram for about 3 years now, so maybe it will work again.
I remember when I first relapsed that I went from 5 mg of escitalpram to 15 mg and tried it for about 4 weeks. It didn't work out (I only had more side effects) and my gdoc convinced me to stop with antidepressants all together. So maybe I didn't give it a fair try and should have gone higher.

My pdoc isn't a doctor who likes thinking outside of the box, so she'll probably won't prescribe anything other than ssri's and ap's. 
 

[CeremonyNewOrder]

Just curious if you are also getting individual/group therapy for your OCD? I ask because I've tried like 90% of psych meds at this point and none have helped my OCD. Both my tdoc and pdoc say therapy is the gold standard in treating OCD. I've been attending group therapy for a year and I do see improvement. Just wanted to share my experience. 

Edited June 17, 2019 by CeremonyNewOrder

[mikl_pls]

1 hour ago, Catwoman said:

Thanks!

So 'selective' is better than 'potent'?

I've been off escitalopram for about 3 years now, so maybe it will work again.
I remember when I first relapsed that I went from 5 mg of escitalpram to 15 mg and tried it for about 4 weeks. It didn't work out (I only had more side effects) and my gdoc convinced me to stop with antidepressants all together. So maybe I didn't give it a fair try and should have gone higher.

My pdoc isn't a doctor who likes thinking outside of the box, so she'll probably won't prescribe anything other than ssri's and ap's. 
 

I wouldn't say selective is better than potent. It just depends on what you need pharmacologically speaking. Like sertraline is pretty potent itself, but also is a dopamine reuptake inhibitor and sigma-1 antagonist (as opposed to agonist, like fluvoxamine). Fluvoxamine and fluoxetine are both not quite as potent as sertraline and paroxetine, but one (fluoxetine) is more stimulating, while the other (fluvoxamine) tends to be on the sedating side. If you need the calming qualities of paroxetine, that would be worth a try, which may get stimulating in higher doses because of the NRI. Fluvoxamine would be a more selective option (for the SERT as well as sigma-1 agonism) if you wanted to try it again. If you need more stimulation, sertraline or fluoxetine would be better.

More potent simply means it takes less of the substance to achieve the same therapeutic effect, generally speaking anyway.

If your pdoc doesn't want to try anything out of the box, maybe your gdoc can step in and help out?

There was someone one here who was getting by on low-dose lamotrigine + memantine alone for their OCD.

[HydroCat]

Adding to what @mikl_pls said, more selective means that more of the substance binds to the receptors/transporters it is selective to, as opposed to being spread out between different ones. In this sense, more selective can be called “stronger”.

Subjectively, Lexapro 10mg felt as strong for me as Sertraline 300mg (or Prozac 80mg). Even more, taking into account side effects.

[Catwoman]

Thanks for the explanation on selective and potent! Really helpful!

The only trouble I had with escitalopram was RLS, but it was still tolerable when I was on 20 mg.  Maybe if I give it a fair trial on a higher dose it could work out. I do remember it was difficult to come off this med. So starting it again isn't a light decision to make.

Is it a good combination with risperidone?  
 

Edited June 18, 2019 by Catwoman

[HydroCat]

SSRI + Risperidone is a good combination. I've tried Sertraline/Fluoxetine with 0.5mg-1mg Risperidone and it worked great.

[Catwoman]

5 hours ago, HydroCat said:

SSRI + Risperidone is a good combination. I've tried Sertraline/Fluoxetine with 0.5mg-1mg Risperidone and it worked great.

Good to know 😀

I do wonder if and how it could be a better combination than clomipramine + risperidone.

Essentially clomipramine is a SNRI, so in theory an AP should work the same as with a SSRI.

[HydroCat]

2 hours ago, Catwoman said:

Good to know 😀

I do wonder if and how it could be a better combination than clomipramine + risperidone.

Essentially clomipramine is a SNRI, so in theory an AP should work the same as with a SSRI.

Right, minus the energizing/activating Noradrenaline boost, which can be good or bad.

Note that Risperidone is on the calming/sedating side of the spectrum.

[Catwoman]

10 hours ago, HydroCat said:

Right, minus the energizing/activating Noradrenaline boost, which can be good or bad.

Note that Risperidone is on the calming/sedating side of the spectrum.

I think I like risperidone. I take 1 mg before bed, but I've taken 0.5 extra a few times during day time when I felt really  uneasy and it helped a bit.
It's not the wonder drug for my issue though, but I'll stick with it for now.

The first few weeks on clompramine I could feel the noradrenergic effects. Getting out of bed in the mornings, more energy and a bit of a antidepressant effect as well. 
I wanted to work my way up to 175 mg to benefit more from the serotonergic activity , but side effects were becoming too much (muscle twitches, constipation, shaky hands and tired legs).

Trying escitalopram again is a guess....it did poop out....

 

Edited June 19, 2019 by Catwoman

[Catwoman]

Sigh, I had to go back to 100 mg of clomipramine.
I noticed I was having more intrusive thoughts on 75 mg. This was actually a dose that never worked for me, but I hoped I could tolerate the returning symptoms.
Which I couldn't.....

 

On 6/17/2019 at 6:53 PM, CeremonyNewOrder said:

Just curious if you are also getting individual/group therapy for your OCD? I ask because I've tried like 90% of psych meds at this point and none have helped my OCD. Both my tdoc and pdoc say therapy is the gold standard in treating OCD. I've been attending group therapy for a year and I do see improvement. Just wanted to share my experience. 

I've had lots of individual therapy for my OCD. I'm not sure if I could benefit from group therapy. But I am active on a Dutch forum and I find it helpful to listen to others and sharing my knowledge about medication and self help.  In my experience medication worked so much better than all the self help books and therapy sessions. Maybe it is because I have such a rare form of OCD. I can't do ERP (which is so important with treating OCD) because I have no rituals. My obsession is to get rid of the intrusive word.
So I am in the OCD spectrum, but I recognize much more from the 'ironic process theory' or 'white bear' problem and I need a therapist who really gets this. I don't have the 'standard' Pure O, so it's difficult for others to relate and I can't relate to others with Pure O because I don't have these kind of obsessions.