Mental Health 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.

 

[paranoid android]

Mirtazapine is a Tetracyclic anti-depressants that has atypical anti-depressant action as it acts as a Serotonin and Norepinephrine enhancer. Mixing it with a SSRI or any other Serotonin reuptake inhibitor can be dodgy but it's done everyday. What other meds have been tried and what type of depression do they suffer from? If they have the sluggish type of depression where they are sleeping way too much and are very fatigued then Bupropion (brand names Wellbutrin, Zyban) could help. If your friend get's insomnia with depression then a sedating anti-depressant such as the Tricyclics Amitriptyline or Trimipramine could be tried.

 

[Chatative]

If they have the sluggish type of depression where they are sleeping way too much and are very fatigued then Bupropion (brand names Wellbutrin, Zyban) could help.

The only problem with that is that Bupropion is it isn't prescribed for depression on the NHS. I'm not sure why that's the case but it is.

All I can say is that it's just a case of trying the various types of medication there are in the hope that one will be effective. It seems to me that your friend has only tried a select few so there still may be hope out there.

Has your friend tried any form of therapy like CBT? Often times people will be much more successful in getting their depression under control if they combine medication with some therapy. For this he would need to have been referred onto mental health services through his GP. It's not clear from your post whether or not this is the case already but I would highly recommend doing so if not.

 

[paranoid android]

WTF? So they don't use Bupropion for depression over there? Christ talk about not covering a perfectly good drug that helps alot of people.

 

[Burnt Offerings]

A low dose amphetamine regiment is sometimes effective for depressive symptoms that are related to lethargy & lack of motivation. (Prescribed off-label, of course.)

 

[OlympicSwimmer]

Ok I do have to say, I was on bupe for about 2 months and it isn't useful in the slightest for pain, anxiety or depression. In fact it would do a lot less good than bad. The drugs your friend was prescribed aren't fast acting, symptom relieving drugs. Many think SSRIS don't do shit for problems. The regimend I would recommend is a low dose, 10-20mg of adderall to help fight the depression and increase motivation, combod with 5mgs of valium in the morning. OH ALSO, he must be diagnosed with depression and anxiety disorder to be prescribed these stronger, scheduled drugs. That means he must go see a psychiatrist or psychologist to be officially diagnosed. Hope this helps!

 

[Drench]

My friend thanks you all for your help and advise.

He used to self medicate and and has tried Buspirone combined with Melatonin, it was not helpful for his anxiety or depression.

How crazy is this?

'Bupropion or bupropion hydrochloride, also known formerly as amfebutamone, is a medication primarily used as an antidepressant and smoking cessation aid.[8][9][10] Marketed as Wellbutrin and other trade names, it is one of the most frequently prescribed antidepressants in the United States,[11] although in many English-speaking countries, including the United Kingdom, Australia and New Zealand, this is an off-label use.[12]'

It's one of the US's frequently most prescribed AD meds, yet here in the UK (and Australia & New Zealand) it is only approved as a smoking cessation aid.

Would my friend be able to ask for help to stop smoking and use it as an AD? I don't think that is the route he would want to take but it just seems ludicrous that it is not approved for Depression.

After a discussion it seems highly likely that my friend has an underlying, undiagnosed form of ADHD. The NHS will not diagnose an adult with ADHD as they believe it is an early-onset condition (from childhood). He has talked with his parents and they agree that his symptoms are almost text-book ADHD. His parents are generally speaking, anti-medication (unless essential) and did not want a drugged up kid. That is something I understand.

His parents are able to offer him support at the GP's surgery by collaborating with him and confirming that ADHD-like symptoms have always been present. I don't think a GP can diagnose ADHD so I think he will need to be assessed by a specialist, before being given the medication that could help him so much.

Dexedrine (Dextroamphetamine) seems to be ideal, it would help him loose weight, gain confidence, make new friends, meet girls, have more energy, improve his focus and concentration and generally be happier. If not Dexedrine then one of the mixed Amphetamine salt preparations. I seems like it would combine well with his current Pregabalin (Lyrica) prescription, as an anti-anxiety agent.

He currently has a bit of a sad life - few friends, no female prospects, cannot work, is always lethargic, overweight-nearing obese (yet essentially he has a strong, healthy core). He is sometimes tempted to take substances to give him some fun/joy and for temporary relief of his symptoms for a few hours.

Life isn't appealing to him, he is not suicidal but he has had thoughts of that kind.

It is quite sad, he used to do volunteer work in the community, yet due to his problems he felt forced to stop (his choice). He would love to do it again as soon as he feels 'well'.

He simply wants to live a normal, happy, productive life and give something back to society. That seems fair to me!

In his later teens he once came across some Dexedrine, he found that when he took them he felt 'normal' for the first time in years. Other stimulants have helped, as well as Buprenorphine. These were all self-medicated, he had the opportunity to try them and was amazed at the results.

Dexedrine made him feel more 'normal' than anything else ever has.

He has started to taper off the Citralopram (SSRI) today and will be off it completely in 2 weeks. Then he will come off the Mirtazepine over the following 2 weeks.

He will be seeing his GP just after he has come off Citralopram. Hopefully things will move quickly once he has discussed the ADHD-like symptoms with him.

At the end of the day life is short, too short to live like a hermit, never having fun with anyone. He would prefer to take a medication for life that helps him feel normal, than to not take anything and feel miserable.

 

[RiseAgain]

I would reccommend looking into CBT to manage his symptoms and start rebuilding his life.

I'm personally very biased against medication, but if your friend is determined to use medication as part of his treatment I think venlafaxine a try.

Venlafaxine is works as an SNRI at low doses and an SNDRI in higher doses. It could help alleviate the symptoms of depression and anxiety but it is a pretty heavy drug and it has a lot of risks and can cause severe dependence, make sure your friend understands all the risks so he can make the right choice for himself.

Venlafaxine increases the amount of seratonin and norepinephrine. It also has a mild dopamine reuptake effect and increases dopamine to a lesser degree. It also indirectly affects opiate receptors which lessens response to pain and enhances its action.

I don't condone the use of these drugs because they can have very severe and sometimes permanent side effects. But that's just my opinion, do whatever you think is best for your friend.

 

[paranoid android]

OP if your friend could find a doctor that was willing to bend the rules a little i'm sure he could get Bupropion. The stop smoking aid is called Zyban which is the exact same as the Wellbutrin SR's. In fact here doctors often give out the generic Bupropion SR's to people wanting to stop smoking to save money because name brand Zyban is a good bit more expensive.

It's definitely one of the most prescribed anti-depressants here in Canada as well. Definitely in the top 3 i would think.

 

[apatheist]

Bupropion is prescribed for ADHD too.

 

[Allein]

WTF? So they don't use Bupropion for depression over there? Christ talk about not covering a perfectly good drug that helps alot of people.

The prescribing of many drugs differs greatly between the US and the UK, pain killers specifically are far more sparsely prescribed and many common US medication isnt available at all. Benzos are also rarely prescribed and when they are its almost always for 2 weeks or less with those on historical long term scripts being forced to taper off.

In some respects I agree with the UK approach, Benzos specifically are not IMHO a good long term treatment for almost all and the over prescription of habit forming pain killers obviously leads to problems. These restrictions and the way the drugs are prescribed (mostly via a national health service) mean that there is little illicit trade in prescribed medication.

The downside is a lack of pragmatism and common sense from many doctors who fail to prescribe the most effective medication even when the patients condition clearly requires it, I've suffered this myself with pain medication and its not great.

I've no idea how effective Bupropion is for depression, I've never heard of it being prescribed here. I spent a long time trying ADs, at the time a desperately needed some assistance to get myself into a place where I could start to help myself. SSRIs just made me ill, physically and mentally, I tolerate TCAs well but they don't seem to do a great deal in the end I found SNRIs did provide some benefit without too many unwanted side effects.

The process took around six months maybe more, it isnt ideal but if you want to go down the medication root you may find you need to work through a fair number of drugs, they react so differently in different people with one person suffering few side effects whilst another suffers severe ones, I am so intolerant of SSRIs that Prozac left me unable to even stand and vomiting profusely within an hour and Sertraline triggered an internal bleed