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Mental Health Desperately need a new antidepressant...again

T

The.Ghost

Bluelighter
Joined
Jun 20, 2011
Messages
274
I’m in a long bout of bipolar depression (several months now, BP-II) and my current regiment isn’t cutting it anymore. I originally asked for advice in OD here and ended up on mirtazapine 45 mg on top of 10 mg aripiprazole and 200 mg lamotrigine. My life changed after adding mirtazapine, but it’s all but lost its efficacy over the years. Now I’ve sunk back into deep depression and alcoholism and I need something, anything, to help. To update the list from the original thread, here’s what I’ve been on in roughly chronological order:

  • Lexapro (escitalopram) – worked for a little while, then made me suicidal
  • Paxil (paroxetine) – same thing
  • Effexor XR (venlafaxine) – worked for a little while, then made me hypomanic, then depressed beyond suicidal. Never going near that shit again. Don't even get me started on the withdrawals.
  • Pristiq (o-desvenlafaxine) – only took this to get off venlafaxine
  • Prozac (fluoxetine) – took it off and on, didn't help overall
  • Lamictal (Lamotrigine) – helps a bit, still on it because, why not?
  • Abilify (aripiprazole) – masked the feeling of depression for a while, but the symptoms were still present. I'm still on it, but all it really does at this point is prevent mixed episodes.
  • Desryel (trazodone) – too many side-effects, only took it 2 days
  • Wellbutrin (bupropion) – took it for ~2 weeks, didn't work
  • Zoloft (sertraline) – took it for a month or two, didn't help. I had nasty side-effects on it and withdrawal symptoms for 5 months after stopping. More here for the curious.
  • Viibryd (vilazodone) – yet another SSRI, didn't help
  • Mirtazapine – worked miracles at first, but not anymore
  • Dextrostat (dextroamphetamine IR) – not really an antidepressant, but I'm on 20 mg / day. I'm only listing it here because some people have said it helps. Not for me.
  • Provigil (modafinil) – same as d-amp, quit years ago
  • Nuvigil (armodafilil) – It's in trials for depression at the moment, but I haven't noticed any mood-related benefit from it. I'm on it for other reasons.

I’m through with SSRIs and SNRIs, I doubt MAOIs are an option because they interact with everything, so I’m looking for something else that may still have some chance of working. I don’t have access to street drugs, so I’m hoping someone can point me in the direction of a pharm that might help. Is there anything left to try? My life has gone right down the toilet the last few months and I need help, even on top of therapy.
 
I've had unwanted side effects from many of the medications you've listed. Have you ever tried Latuda, Zyprexa (olanzapine) or Saphris? I had a bad reaction from Latuda but have a friend that it worked well for. Try talking with your doctor about tweaking your meds. Also cutting back on alcohol because the medications won't work properly when you're drinking a lot.

I'm going to move this to Mental Health where perhaps more people can share their experiences. Wish you luck.
 
I put on 40kg when taking Lexapro and couldn't take it off now matter how hard I tried. Cymbalta on the other hand worked ok as a antidepressant. i keep on saying I'll get off this garbage after taking it for 6 years but can't bare the side effects SSRI's give.
 
Cymbalta/Duloxetine worked well for me for awhile after not liking Effexor. It's more balanced and is much more tolerable. Your good response to Mirtazapine may suggest your depression benefits from stimulating the adrenergic system (as SNRIs do).

Also agree with T. Calderone on atypical antipsychotics. If it's BPII, then some antidepressants could make it worse. (Prozac, which has a mood stabilizer mechanism, is sometimes an exception to that, but you already tried it.) Seroquel is another one, and it juices up the adrenergic system pretty well. Your tolerance of Mirtazapine suggests you can handle some H1 receptor sedation.

Lithium can be hit or miss or depression, but when it hits (as it does for me), it can have very minimal side effects and a very useful stabilizing effect, including a lower (statistical) risk of suicide.

Overall, your medication history sounds more like that of someone with treatment resistant unipolar depression. Maybe moving more in the direction of mood stabilizers and BP meds would help.
 
I've been on lamotrigine 200 mg, mirtazapine 45 mg, and aripiprazole 10 mg for 7.24 years now. (Note the number of significant figures -- I keep a daily log of literally every psychoactive pill I take). I only took olanzapine (2.5 -- 10 mg) for sleep (severe chronic insomnia), but I'm not sure if it ever helped with depression. My mood was rock-solid stable at the time, but correlation and causation. As for lithium, I'd need a renal function test before downing any. I come from a medical family and had to leave my previous psychiatrist because he proscribed lithium without one. Lastly, quetiapine is one I'd get depressed on sporadically, I don't think that would help much.
If I sound a bit incoherent, it's because I've slept a total of 8 solid hours since new year's.
 
Aripiprazole is weak on the depression end of bipolar disorder, and so it's usually paired with a mood stabilizer like Lamictal, as you're taking. (https://www.medicalnewstoday.com/articles/248385.php) Quetiapine and Olanzapine and Risperidone, which are somewhat older, have often been thought of as more effective for both mania and depression ... but ... the data backing that up could be spotty. Sometimes with BP frickin Haldol is the ticket. Or one of the newer APs with a better reputation for depression. The idea that Abilify is great for unipolar/bipolar depression is mostly marketing and not backed up by science. It's a good med in certain cases, but it's probably not the battering ram you're looking for.

Stahl's 4 ed. ranks Lamictal as having the the most kick, among anticonvulsant mood stabilizers, for bipolar depression. It also lists the following combos as having a good reputation (if not specific research as backing):
Lamictal + Valproate
Lamictal + Lithium
Lamictal + Seroquel (or one would assume Zyprexa)

Other options include tacking on an AD to any of the above (the "California careful cocktail"). Which is kind of where you are now, except with Abilify.

Good luck, bipolar depression is one of the most difficult things to treat.
 
I'm not a doctor, but just reading your first post, it doesn't sound like you took many of these as directed. These are extremely powerful drugs. You can't just take them "off and on", or for a couple of days, or even two weeks. Did your doctor not tell you that these types of medications often take a week or more before you even begin to feel any effect? And that you need to give it up to month to see how you adjust to it?
 
The only reason I'm on Abilify is that it prevents mixed episodes completely. For that, it's worth it weight in gold. It has little anti-depressive effect on me.
I took everything as directed. When I said "off and on", I meant 3+ month periods, dose every day. I'm well aware that AD's take time to work.
 
The.Ghost said:
The only reason I'm on Abilify is that it prevents mixed episodes completely. For that, it's worth it weight in gold. It has little anti-depressive effect on me.
I took everything as directed. When I said "off and on", I meant 3+ month periods, dose every day. I'm well aware that AD's take time to work.
Click to expand...

Okay, I didn't mean to insult your intelligence or anything. I went through a similar experience, but you seem to have me beat on the variety of things you've tried. If you have truly given all of those medications a fair chance and you are still suffering I would personally consider changing doctors. If you've been to multiple doctors over the years I assume you kept them updated on everything you had tried. Honestly, I don't think most doctors who aren't specialists really know what they're doing when they start trying to treat someone for something like this. The doctor I have now, pretty much the only one I've ever trusted on these matters, admitted to me that its like throwing a bunch of pills against the wall and seeing which ones stick.

SSRIs were poison to me. SNRIs not much different. The only thing I ever had any success with was bupropion. If you really only took it for two weeks it might be worth looking into again. I liked it but had to stop because I was having sleep paralysis pretty much every night and terrible nightmares.
 
Are there specialists for refractory depression? I don't remember why I went off bupropion, may be worth another shot. I think I'll give olanzapine another try. It is FDA approved for BP-I depression and I'm starting to think it may have had some effect.
 
I've been on several antidepressants over the years and I can't help but wonder whether any of them really do anything, or that if they do work how much of it is down to the placebo effect.

I also was put on Aripiprizole, an antipsychotic, for a while and I couldn't tolerate it. It was horrible - made me feel really strange. I couldn't concentrate on anything and couldn't sit still for a minute. I didn't like that at all.
 
In theory, every psychiatrist should be an "expert" at refractory depression since they tend to handle the more difficult cases, with general practitioners handling most of the lower end. Unfortunately, the current state of psychiatry is that even if you're at the top of your field, you're still doing an awful lot of guessing and throwing shit at the wall to see what sticks.

I associate the following with a doctor being more progressive/aggressive:
Openness to ECT (modern shock therapy, which is seeing a revival ... a lot of more traditional doctors are only willing to use it as a last resort)
Openness to Ketamine therapy, or even DXM off-label (http://www.mdmag.com/medical-news/can-cough-medicine-treat-depression)
Genetic testing (attempting to predict what medications you might respond to well)
Paying close attention to thyroid function (not all doctors do this when treating depression)
Any kind of treatment that targets the stress system (could be asian ginseng or even short term mifepristone)
Transcranial magnetic stimulation or transcranial direct-current stimulation

If you're willing to do more alternative treatments, and pay for it, it can help to tell your doctor plainly. My old doctor would always say, "Well, I'm thinking about the financial cost as well." But if your ass is on fire, money isn't so important.

As far as antidepressant effectiveness, the statistics aren't great (https://www.nimh.nih.gov/funding/clinical-research/practical/stard/allmedicationlevels.shtml). It depends on how you define success. If it just means "makes the person feel better," those numbers are high (and higher than placebo). If you define it as trials sometimes do as a 50% reduction in symptoms, that's more difficult. And if success=remission, the numbers are close to placebo, which many critics point to.

For me, pharmaceuticals are often slow and crappy, but they're reliable, and have been since I found a few that worked well (Lithium, Seroquel, Remeron, Prozac) for depression with psychotic features (unipolar). I'd certainly like to be less sedated, and am looking into that with a new doctor.
 
First I’m an alcoholic too. It’s been many years since I drank. The best thing I did was get into rehab, Meds don’t work with alcohol. I’ve been dealing with chronic PTSD for decades, first by drinking. It’ll be 30 years without a drink this Summer. Since I’ve endured 30 years of PTSD therapy and Meds. My story begins after I stopped drinking.
My worst symptoms were paralyzing morning depression and anxiety.
I’ve been on many of the Meds you mentioned. But all eventually failed or ever truly delivered the results I sought.
Then my wonderful young daughter was diagnosed ADD and prescribed Concerta ER. The wonderful change in her filled our hearts with joy. She described a newfound ability to concentrate, and was now enjoying school. One morning I tried one of her Concertas. It was the first morning in years I didn’t struggle to get out of bed to do something, anything. I told my Psychiatrist I was preparing for a Tech Certification exam but my depression was making the required concentration impossible. I asked if I could try Concerta, he agreed, having already tried everything else. My life changed. I was able to be productive, the depression disappeared. It was truly amazing. I can’t begin to describe the difference in my life before and after Concerta. In what is typically the case, over the following years I required larger doses. Each increase worked. After several years Concerta finally stoppped working. The same happened to my daughter. Her Doctor switched her to Adderall ER and additional immediate Adderall.
I requested the same from my Doctor. That was at least five years ago. As of today I’m living life, a real life. Occasionally I’ll have a brief, shallow episode of depression. But these episodes are like a case of the sniffles compared to my previous multiple month, or all winter long depressions. I just want to say that Concerta and Adderall have done for me what no Anti-Depression Med ever did.
I’ve done this under the supervision of my Doctor. I hope this sheds light on a non traditional approach to PTSD, depression and anxiety. Whichever path you choose I wish you the very best.
 
Latuda, my friend. Another - lithium. Gotta stay on the med, though. Be consistent. It's not Advil.
 
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