Mirtazepine + Citralopram - Not working. What are the options?

[Drench]

Hi, a friend of mine is prescribed 15mg Mirtazepine (tricyclic AD) before bed and 20mg Citralopram (SSRI) in the mornings. He has previously tried Sertraline (SSRI) and Venlafaxine (SNRI) with no success.

He has gave them time start working properly (6 weeks+) but he still doesn't feel much, if any, relief.

His main problems are depression, anxiety, lack of motivation and he can find it hard to feel pleasure from usually pleasurable activities.

I've helped him look at the options available -

1. Dosage increase of one or both meds.
2. Alternative certified anti-depressants.
3. Other meds that could help, off-label.

He doesn't feel that increasing the dosage would help, and he doesn't like having these AD meds in his system. He has looked at other AD meds and there seems to be nothing that offers more than a SSRI/SNRI/Tricyclic AD. He wouldn't consider MAOI's because of the risks, side effects etc.

He has researched off-label meds which have been successfully used for depression, anxiety, motivation etc. and the best option seems to be Buprenorphine (Subutex/Suboxone/Temgesic). It is usually prescribed for opiate addiction and pain (on-label).

His doctor is unwilling to trial any meds 'off-label' as it could result in him losing his license - this seems fair.

What would be his best option be now? To ask for a referral to a (prescribing) Psychiatrist who may be willing to try something off-label? He doesn't know what else to do.

What makes the situation slightly crazy - he could say he was addicted to opiates, give a couple of samples positive for opiates, then be offered Subutex/Suboxone/Methadone, at a much larger dose than he would need to use it for his problems. This is not something he would consider, as deceit is not in his nature.

He is in the UK and cannot afford 'Private' Healthcare, like most he can only use the NHS.

I have suggested that he requests an appointment with a prescribing Psychiatrist.

Any other ideas?

Thanks.

D.

 

[lurching]

The chance of any psychiatrist prescribing him an opioid painkiller for depression is going to be very small. Just how severe is this depression?
The psychiatrist may raise an eyebrow when your friend says doesn't want to try an MAOI antidepressant because of the risks yet he's fine with a strong opioid like buprenorphine.
ADHD medication (Ritalin or, preferably, Dexedrine) are more likely to be prescribed for a depressed mood and lack of motivation (but, of course, only when there's ADHD symptoms found as well). Lyrica can be very useful too, it has done more for my mood than the SSRI/tricyclics I've tried, and can be combined with dex quite well in my experience.

 

[hexagram]

I hated citalopram, couldn't sleep on it, couldn't cum, made me feel worse tbh.

I self medicate with alohol and benzos, which is a poor choice which I wouldn't reccomend to anyone but it helps me feel ok and enjoy my day.

 

[Drench]

The chance of any psychiatrist prescribing him an opioid painkiller for depression is going to be very small. Just how severe is this depression?
The psychiatrist may raise an eyebrow when your friend says doesn't want to try an MAOI antidepressant because of the risks yet he's fine with a strong opioid like buprenorphine.
ADHD medication (Ritalin or, preferably, Dexedrine) are more likely to be prescribed for a depressed mood and lack of motivation (but, of course, only when there's ADHD symptoms found as well). Lyrica can be very useful too, it has done more for my mood than the SSRI/tricyclics I've tried, and can be combined with dex quite well in my experience.

Yes, it is a strong opiate painkiller (my friend is already taking weaker opiates for pain) so it would kill 2 birds with 1 stone. Despite the strength it is only a partial-agonist at the opiate receptors, which means less/no euphoria, it's very hard to OD on and it prevents almost any other opiate from working.

There are several examples of Bupe being used for depression/anxiety/motivation/mood here.

Apologies if I come across as defensive, it's just that I've done as much research as possible for my friend.

Ritalin/Adderal/Dexedrine (amphetamine salts) was the other drug I've been looking into but I wrote it off because I thought it would make the anxiety worse. Although it would help with mood, motivation and weight which would be great. There is no ADHD diagnosis although the symptoms are present.

He is also on Pregabalin (Lyrica) which helps him a lot with mood, anxiety and motivation, he feels it's just not quite enough on its own.

I've linked him to the thread and had a chat and he would consider trying something like Dexedrine. Would you suggest that he mentions the ADHD-like symptoms to his GP?

Is anyone here in the UK prescribed Ritalin/Adderal/Dexedrine?

 

[F.U.B.A.R.]

I self medicate with alohol and benzos, which is a poor choice which I wouldn't reccomend to anyone but it helps me feel ok and enjoy my day.

Oh aye, it works so well that you've threatened to top yerself numerous times in the last few weeks...

 

[Drench]

My friend has tried the whole 'self medicate' thing and it only made his problems worse in the long run. Not recommended.

 

[andy-777]

I'd say that a 15mg dose of mirtazapine is fairly low, would think that 30 or 45mg would be much more helpful for anxiety/depression. Hope that's some help, but definitely tell your friend to avoid 'self medication'

 

[JG0007]

Mirtazapine, I took these off my mate to sleep. Maybe it was a stupid idea but they were fcuking weird. I slept but I had crazy dreams where I was being chased all the time. Probably not a lot of help to your question but them Mirazapine = fcuked up.

 

[Sadie]

Mitrazapine for me were amazing. Were prescribed them for depression a few years ago. Great sleep, not much fall out the next day ( I.E. being groggy )

I'm now prescribed Amitriptyline. 10mg for pain but I can't seem to really wake up the next day. It's like wading through fog for me. Stopped taking them. I can't hack that. Perhaps over time I'd get used to it and I wouldn't notice it. Sure it gets me to sleep but the fall out the next day isn't worth it IMO.

Everyone is different though.

 

[Ceres]

mirtazapine good for appetite and regulating sleep. SSRIs im not convinced do much.

Methoxetamine or 3-meo-pcp solve all my problems but that may be using a sledgehammer to crack a nut. Everyone is different. Noone has the answers unfortunately.

NMDA antagonists help with my depression much more than any prescribed medicine, especially for acute periods of depression. One day these will be frontline anti-d medicines one can only hope, at the moment there are some in stage 3 clinical trials.

 

[Chatative]

NMDA antagonists help with my depression much more than any prescribed medicine, especially for acute periods of depression. One day these will be frontline anti-d medicines one can only hope, at the moment there are some in stage 3 clinical trials.

I'm not sure if it's done in the UK but ketamine treatment for depression does exist in the US.

 

[Ceres]

I'm not sure if it's done in the UK but ketamine treatment for depression does exist in the US.

It's being trialled in the UK as treatment for acutely depressed suicidal patients, and also as part of the anaesthetic for electroshock therapy (in research).

Ketamine works but the pharma companie are working hard to come upw ith a medicine which doesnt have the 'psychedelic' side effects.