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Mental Health Patients non-responsive to SSRI's - augmentation protocol??

JohnBoy2000

JohnBoy2000

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I'm just curious as to what the typical protocol for follow up treatment is for patients that have not or only slightly responded to SSRI's, SNRI's or mirtazipine?

I understand sometimes there are adjuncts with anti-psychotics?
Such as olanzapine with fluxotine.

Do they ever add in respiradone or seroquel?
Even without comorbid psychotic features?

The next go to approach would be, I would guess Bupropion/Wellbutrin, being a pure noradrenergic?

I've read anecdotally that Aripripazole is also used as an adjunct?
Wikipedia tells me that that has a fairly nasty side effect profile, and is not fit for use in geriatric patients.

The other anti-psychotic that springs to mind would be, Lamictal.
Often used?
A go-to thing?


Beyond that, I know that there would be a trial with tricyclic AD's.

And failing that, MAOI's - worst case scenario.


Have I nailed the pertinent effects?
Or is the typical protocol a little more diverse?

The clinicaltrials.gov website seems to have conducted the majority of it's trials in terms of non-response to first line SS/NRI's, with Bupropion or Aripripazole.
 
Is this the appropriate sub forum to post this in??

Cause I see the other threads are basically discussion about how to get high...

This might be a little out of place here, no?
 
I will move this to Mental Health and hopefully, you will get some responses.
 
If you go in for anxiety, they usually give you just about all that crap before you get to any narcotics.

Things like benzodiazapines and barbituates are considered a last resort in medicine.

I really can't advise you either way, not here to help you score drugs.

If you want to discuss the condition you suffer from and what they will give you in what order I could probably address that as to what I went through to find something that worked for anxiety.
 
dopemaster said:
If you go in for anxiety, they usually give you just about all that crap before you get to any narcotics.

Things like benzodiazapines and barbituates are considered a last resort in medicine.

I really can't advise you either way, not here to help you score drugs.

If you want to discuss the condition you suffer from and what they will give you in what order I could probably address that as to what I went through to find something that worked for anxiety.
Click to expand...

Not for anxiety.

For depression.

Clinical, endogenous, refracted - all that good stuff.
 
well i have depresion/anxiety and symptoms that run with it..WElbutrin helped perk my mood a little bit, i seemed more activated a interested in life but my anxiety increased!after a month or so the good effects were gone and i got off

Selegiline is similar to Welbutrin for me, but a little more effective..it has officially pooped out though..

SSRIs have all been a dead end for me, made me worse in several areas..

intense daily exercise helped me for years but its extremely hard to push your body harder daily to get 2-3 hours of relief so..

tell us what your major symptoms are..
 
i suffer from severe, treatment resistant depression. I'm on an SSRI (Fluvoxamine 300mg/day) , in addition to an anti-psychotic (Risperidone 3mg/day). The combo is working for me, the ssri alone wasn't enough for me i guess.
 
Low doses of Seroquel XR and Abilify are indicated for boosting antidepressants in patients with lesser responses to them. Risperdal, afaik, is not indicated for this but as you see, it too may indeed work.

Abilify generally has a better side effect profile than most antipsychotics, be they typical or atypical. Primarily because it seems to be more weight neutral and have lower metabolic effects (blood glucose, lipids etc.) Some feel it may cause more restlessness than others but this is only anecdotally, not sure what the literature says exactly. And all antipsychotics are contraindicated in people over 65 with dementia as it increases their risk for stroke and many appear on the Beers list of drugs that are normally inappropriate for geriatric use.

I think your thoughts on the progression of treatment options is good. Try and "fail" a couple SSRIs or SNRIs, try a AP boost, switch drugs to different class. There are other drugs that are used for depression when SSRIs fail. Tricyclics, trazodone, and even MAOIs and amphetamine have their place and must be explored in treatment resistant cases. Also, I am more and more liking Trintellex, a newer AD that has both SSRI and serotonin receptor agonism at 5ht 1a and partial agonism at 1b. Dont forget to have your thyroid levels checked as well, as hypothyroidism can worsen clinical depression.

Lamictal seems to work best in bipolar depressive states, but worth a shot if nothing else does work. Titrate up slowly (about a 25mg a week increase) to help reduce risks of serious skin reactions.
 
adding lithium is one of the oldest augmentation strategies, its believed to work through the enhancement of serotonergic neurotransmission.
 
Main symptom is low energy, low appetite, insomnia.

Social withdrawal - but I see that as a product of the tiredness, and the fact that my personal hygiene and presentation suffers drastically without the application of correct meds, so of course I can't really socialize in that state.

When I'm functional, I socialize very well indeed.

"Sadness", per se, is not an issue at all and, in consultations with shrinks, it's a tremendous challenge as I don't come across as depressed, so they won't write me meds.

There were no precipitating factors.
It just came totally out of the blue and fucked my life beyond all recognition.


And lack of concentration; I can't read for sustained periods any more, can't study etc.

I guess that amounts to "cognitive impairment".

Abilify has a reputation as a depression booster, but clinical trials say that it does not improve actual personal functional levels.

I'm just two week on bupropion now and, I have felt good effects with it, but I assume it needs more time to reach a better efficacy.

My non response to SSRI's or any pure serotonergics, as well as my partial response to mirtazipine - which incorporates noradrenaline affects - kind of makes me deduce logically that it may be more noradrenaline implicated in my condition.

One clinical trial dictates that serotonin is more effective for "sadness" type depression also, and predicts non-response of cognitive impairment to fluxotine, as was exactly the case with myself.


In terms of alternate noradrenaline based AD's - I'm really hoping bupropion works out case, my alternative is,

- nortriptyline

Which has more side effects and is known to induce sedation - which I'm trying to counter.

Or,

- Strattera

which is indicated for ADHD, and does not have a reputation as a particularly effect AD.

There's also

- reboxetine

Which also has a terrible reputation in terms of efficacy.
 
If you don't mind me asking how old are you and have you previously used any recreational substances?
 
I'm 30 years old.
Had this illness for 10 years.
And I never used a recreational drug in my life.
I don't drink alcohol, never have, and I don't smoke anything - nor have I ever.

Athletics is the focal point of my life.
Diet and lifestyle are excellent (functionality relative to this illness permitting).
 
Hi JohnBoy
You're story sounds similiar to mine, I too posted something on augmenting with an anti depressant. Am on Welbutrin xl 350 mg and have a lot of moodiness, crying, irritability. I"m not bipolar; PTSD with anxiety and major depressive is my dx. I too do the natural stuff, exercise, dietary, counseling. Its frustrating. Lamotragine worked for about a year, or seemed to. Now we're trying different strategies...but at what cost? Some of the side effects suck. Like the weight gain; just lost some I'd gained with Celexa...I was told that some of the drugs actually make you gain weight by how they affect your metabolism, so no matter your eating or exercise you can still gain. It is frustrating. Just wanted you to know you're not alone and I'm interested in following this thread to see what you find out.
 
Yeah so "augmentation" is their fancy word for practicing polypharmacy...for better or worse.

Effexor becomes stimulating at around doses of 150mg.

Augmentation with low dose ability isn't bad. Abilify can produce horrible restlessness, but side effects relative to other aps are mild. I'd trust your doctor before looking up studies. At least until you give them a real chance at treating you. Antipsychotics overall in small doses can help.

Lamictal is a mood-stabilizer, but works well on the depression side. As is, and does, lithium.

Something to keep in mind is to keep away from self-diagnosis and thinking that "oh, I'm more tired, so I must need a stimulating drug" or something. Depression itself can cause a range of things such as fatigue, insomnia, overeating, under-eating, social withdrawal, all kinds of anxiety, impaired cognition, and more.
Sounds like Wellbutrin might work for you.
 
More cognitive approaches like mindfulness meditation for insomnia are definitely something to consider. Insomnia can be the root cause of a lot of issues for many people.

Risperidone isn't horrible at lower dosages (for me around 1mg is a lower dose) but it can certainly cause dysphoria/anhedonia at higher dosages (like those typically used to treat schizophrenia, 4mg or so). But it would be better to try Seroquel first, its a little less hardcore if you will.
 
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