new rx combo - strattera and vyvanse

[Shady Kaity]

My psychiatrist just rx me strattera ontop of my vyvanse.
Why is this? Like what is the purpose?
I'm on 70mgs vyvanse and now on 40mgs strattera. And what struck me as strange is he wants me to take the strattera at nighttime.?
Opinions on this?
And on occassions ill take 140mgs of vyvanse, would that still be safe?

And he also. Gave me topamax, idk much bout this one if anyone could inform me.

And a side note, I'm on cymbalta too, if that matters at all. As well as prednisone and plaquenil.

 

[tokenname]

There are times where an md. will add on another shorter acting add/adhd med..
if there are complaints that the 1st med isn't doing what it should..losing effectiveness..
wearing off..etc.

Nighttime is weird..i would think afternoon..if it was to be an add-on for adhd.

I think what I'm saying is it's not unheard of to combine 2 adhd meds for better effectiveness..
but besides that I don't know what I'm talking about.
I wish you good luck with better answers, though.

-token

 

[OpiumKing]

I can help you out with the Topamax a little: It can be used for many, many disorders.! Did I say Many enough.? The one thingI LOVE about this drug is it will take away just about any kind of headache.! Not just Migraine, but really bad tension headaches ...the kind of headaches you get from too many nights up, and not enough sleep, and bad opiate withdrawal headaches that I get sometimes. 50 mg should do the trick, but you can take 75 - 100 mg if needed. Don't take them every day, cause it will mess with your memory big time. So I just take em for those really Mean Headaches. Hope this helps

 

[Alex000]

Vyvanse, Cymbalta, and Strattera? This just sounds like seizure-city. I would not start taking this Strattera, at all. Seriously, the combo of those three meds sound very dangerous to me. Even combining two of any of those three would have me concerned.

 

[Geaux Tigers!]

My psychiatrist just rx me strattera ontop of my vyvanse.
Why is this? Like what is the purpose?
I'm on 70mgs vyvanse and now on 40mgs strattera. And what struck me as strange is he wants me to take the strattera at nighttime.?
Opinions on this?
And on occassions ill take 140mgs of vyvanse, would that still be safe?

And he also. Gave me topamax, idk much bout this one if anyone could inform me.

And a side note, I'm on cymbalta too, if that matters at all. As well as prednisone and plaquenil.

Disclaimer: This is my area of professional consult; however, please discuss everything with your own PDOC.

Kaity, what are your dx’s? First of all, I will answer your questions that do not require an opinion. Later, I will give you my opinion which is a lot more ‘fun’.

Your PDOC augmented the Straterra (atomoxetine), a selective norepinephrine reuptake inhibitor (NRI), to your Vyvanse (lisodexamphetame) for the indication for ADHD (314). Atomoxetine, like many psychotropic medications, may cause somnolence during the daytime; thus, it is commonly advised to be taken QHS.

Take your medications as prescribed by your PDOC. Proceed with caution, but I believe that it would be perfectly safe for you to double your 70mg. Vyvanse dose to 140mg. 140mg. of lisodexamphetamine (basically, think of the lysine molecule, the –lis, as adding “extra weight”) is roughly equipotent to 63mg. of dexamphetamine freebase. (Basically, 2 X Dexedrine Spanule 30mg.) This is not an unheard dose of d-amp for ADHD management.

Topamax (topiramate), I presume, is prescribed for a Bipolar disorder or ADHD (there is limited evidence that topiramate may be efficacious for ADHD), Kaity? (Do you have epilepsy?) I’d be interested in what mood stabilizers/anticonvulsants you’ve been prescribed in the past. Topiramate is a pharmacologically interesting drug. Like other medications in its class, it very roughly (I’m not writing a paper about the pharmacology of topiramate and other anticonvulsants here; give me a break.) includes inhibition of voltage-dependent sodium channels and certain GABA release mechanisms. It is a derivative of fructose which is interesting, think of Neurotonin (gabapentin) and Lyrica (pregabalin) being derivatives of GABA, and honestly I think both of these drugs would likely be more effective than the indication of Topamax for a lot of disorders. Topamax is one of the few in this class that can help—and is sometimes prescribed— you lose weight.

Off-hand, I don’t see any reason why any of these medications would interact with your Cymbalta (duloxetine); Predisone; or plaquenil (hydroxychloroquine); if concerned, check out the drug interactions page on drugs.com I do see some probable cause for some seizures from taking Cymbalta, Straterra, and Vyvanse concomitantly. Maybe this is why he wrote you topiramate?

Now let’s get into my opinions.

Atomoxetine is a shitty drug. I would not write this to augment ADHD treatment without you having first tried Wellbutrin (bupropion), Intunive (time-released guanfacine), or a tricyclic AD like imipramine or desipramine. I believe that stimulants are the gold standard and really the only things that 'truly' work for ADHD, but I can see alternative medications being positive. Atomoxetine is a failed antidepressant and gives you crappy side effects without much purported benefit. I would advise you to research to see if you even want to take this medication.

Topiramate is not a bad drug; I can understand it completely for:

A. Augmenting another mood stabilizer for treatment of Bipolar Type II, rapid/mixed cycling.
B. Migraines
C. Epilepsy
D. Alcoholism
E. Weight Management (trialing it in combination with phetermine for this)

Like atomoxetine, topiramate seems to be one of these “trendy drugs” (so sometimes prescribed by people who have no idea what they’re doing) for a wide range of psychiatric disorders when there is a better drug available. It might work for ADHD, it might not. You need to watch out for cognitive dulling with this drug. It is nicknamed “Dopamax” for a reason.

I’m not your PDOC so I can’t give you proper medical advice, especially since I do not have access to your diagnoses and medical history.

Hope I could help a little!

 

[Geaux Tigers!]

I didn't even bother to read the responses before I posted lol.

There are times where an md. will add on another shorter acting add/adhd med..
if there are complaints that the 1st med isn't doing what it should..losing effectiveness..
wearing off..etc.

Nighttime is weird..i would think afternoon..if it was to be an add-on for adhd.

I think what I'm saying is it's not unheard of to combine 2 adhd meds for better effectiveness..
but besides that I don't know what I'm talking about.
I wish you good luck with better answers, though.

-token

I get what you're saying about afternoon dosing with ADHD medications but atomoxetine is an exception to this; think of it similarly to how you would dose a SSRI. It takes some time before it begins to "work".

Vyvanse, Cymbalta, and Strattera? This just sounds like seizure-city. I would not start taking this Strattera, at all. Seriously, the combo of those three meds sound very dangerous to me. Even combining two of any of those three would have me concerned.

Agreed 100%.

 

[Shady Kaity]

I have many dx actually lol...let's see...bipolar type one, severe clinical depression, GAD, social phobia, adhd,, bpd, impulse control disorder, bulimia (although I'm not sure if I agree with that), and PTSD. And physically, were workiing on a dx of it seems to be lupus, or rheumatoid arthritis. I'm in constant pain and endlessly exhausted. And basically no pain medication helps for that. I took oxy 10mgs 800mgs skelaxin, naproxen and tylenol and got such minimal relief, I still was unable to sleep through the pain. :/
I've tried soo many different medications, many of them give me adverse reactions, and or do basically nothing.
Prozac- was alright in the beginning, but soon stopped being effective although tried for an extended period of time, dr thought it was time to try something else
Seroquel- even low doses of 150mgs knocks me thee fuck out and actually was the main reason why I had stopped attending hs cuz id sleep for literally 14-18hrs, impossible to wake me up.
Geodon- caused double vision which terrified me
Lamictal- rash
Wellbutrin- tried while pregnant, caused severe scary rages. Was always irritated.
Abilify- taken as a teen made me suicidal, but when tried again about a year ago seemed okay. But once on the vyvanse, caused me to have bad come downs
Saphris- difficulty swallowing, weird and scary
Trileeptal- didn't take it long enough bc I read it affects effectiveness of birth control. No more babehs pls.
Intuniv- nothing happened at all.
Strattera- tried a few months ago, eventually stopped taking it cause I. Shake really bad on it...which after taking it last night, I already am shaking badly again
I'm probably blanking on others, too.

Currently the cymbalta helped with pain in the first week, but unforunately seems to have stopped, but maybe that's due to my condition worsening idk.
I honestly can't even tell you if I feel its helping my mood. I've been so overwhelmed and feel helpless and I just don't know anymore.
Ugh. Fml, sorry for the long sob story.
All the input from you guys is great and I very much appreciate it

 

[ErgicMergic]

Choose between either the Cymbalta or the Stattera, since it's dangerous to have two NRI's together due to seizure risk, especially with Vyvanse in the mix. Plus, anxiety goes up way high, since too much adrenaline (NE) tends to cause anxiety and "tweaking," which could be the reason you're feeling overwhelmed.

Strattera + Vyvanse can actually be very effective for ADD when taken together. The Vyvanse will act as a slowly converted Dexedrine (increasing Dopamine), while the Strattera takes care of the NE boost, like from the L-amp in Adderall.

140mg Vyvanse is a bit much... that's equivalent to 45-50mg Dexedrine released over the day, I would stop abusing the script if you genuinely need it for ADD.

 

[OGKooosh]

im not saying to blatantly disregard what your doctor has prescribed you. but given his track record has any of the shit hes given you helped you?

 

[tokenname]

^^^simple perfection^^^




"I get what you're saying about afternoon dosing with ADHD medications but atomoxetine is an exception to this; think of it similarly to how you would dose a SSRI. It takes some time before it begins to "work"


...a most useless place. The Waiting Place...


Instant gratification is so gratifying.

token

 

[Geaux Tigers!]

Sorry to hear about your pain! That esoteric pain must be the worst thing ever! It is lugubrious that opiates are ineffective for you; however, it might be a good thing if you’re prone to addition like me. Opiates have done a mountain of damage to my reputation, my career, my family and my finances; but that’s a story for another day.

Wow, I can’t believe he still insisted on Straterra after your bad experience prior and the seizure risks. Sounds ridiculous stupid.
I noticed that the only medication that seemed okay was Abilify (aripiprazole), but I understand you not wanting to deal with that side effect, so I see your doctor tried different antipsychotics (AP): Geodon (ziprasidone) and Saphris (asenapine). Besides the ziprasidone double vision and the weird and scary effects of asenapine, how well did you respond to these antipsychotics in terms of treatment?

Depending on whether you had any kind of positive response to them, perhaps you should try yet another one? I don’t disagree with your PDOC trying ziprasidone after a discontinuation of aripiprazole, but I do think that a better AP could have been selected after ziprasidone discontinuation than asenapine since they both pharmacologically target the same receptors that may have been responsible for your negative side effects. I would have selected lurasidone instead of asenapine; also, I still suggest it, but only if you think you would respond positively to an AP. Lurasidone is an under-medicated AP, in my opinion. It is the least impairing cognitively but Iam considered about akathisia.

I AM NOT A FAN OF ANTIPSYCHOTICS AT ALL BUT I DO KNOW THEY HELP SOME PEOPLE.

I still need to know what you’re having problems with and what you’re looking for out of a medication. I’d love to give you advice but it’s hard to do it without what you desire and what your problems are.

Have you looked at alternative PDOCS?

 

[Geaux Tigers!]

Choose between either the Cymbalta or the Stattera, since it's dangerous to have two NRI's together due to seizure risk, especially with Vyvanse in the mix. Plus, anxiety goes up way high, since too much adrenaline (NE) tends to cause anxiety and "tweaking," which could be the reason you're feeling overwhelmed.

Strattera + Vyvanse can actually be very effective for ADD when taken together. The Vyvanse will act as a slowly converted Dexedrine (increasing Dopamine), while the Strattera takes care of the NE boost, like from the L-amp in Adderall.

140mg Vyvanse is a bit much... that's equivalent to 45-50mg Dexedrine released over the day, I would stop abusing the script if you genuinely need it for ADD.

You're right; the NRIs do lower the seizure threshold. NE release isn't that great for generalized anxiety but it can be effective for social anxiety, see: venlafexamine and paroxetine. I'm not sure about tweaking even though I see your point since a lot of NE meds do promote that, e.g. bupropion and stimulants. Not so much with SNRI and some in this NRI (lol definitely not methylphenidate) Atomoxetine causes fatigue in a large number of treated individuals. I don't think that the duloxetine and atomoxetine would necessarily promote this "tweaking" effect beyond what she's getting with d-amp. Point is, the NE boost, in terms of stimulating adrenergic effects, from atomoxetine can't be compared to l-amp. I would say that bupropion would be more suited for what you're talking about.

Atomoxetine acts as an NMDA receptor blocker in clinically relevant concentrations so that might explain some of its beneficial effects on ADHD treatment. Yeah, I suggest not abusing your script too, but it's not the end of the world to double up sometimes. Have you tried out any other stimulants besides Vyvanse? I'm a big fan of the Dexedrine 10mg. IR. I'd ask for #90 10mg. dextroamphetamine sulfate; PO, two tablets QAM, 1 tablet QPM for 314.01. This is so you can better control your dose while using the same d-amp.

 

[Geaux Tigers!]

Which of your dx's are not being properly treated? Give Topamax an honest chance. Basically, given your entire history of what you're taking and what you're diagnosed with. I'd taper off Cymbalta and switch to imipramine or something else. Also, I'd get you titrated to a proper dose of lithium. Do you think your Borderline Personality Disorder/Impulse Control Disorder needs an AP? I suppose you can give Latuda a shot.

Disclaimer: I took these way too seriously and put too much thought into it. I enjoy doing this, it's my career and my life lol.

My new magical cocktail. About to get into this.

#60 900mg. lithium; PO, 1 tablet QAM, 1 tablet QPM for 296.5
#90 10mg. dextroamphetamine sulfate; PO, two tablets QAM, 1 tablet QPM for 314.01
#30 125mg. imipramine PO QHS for 296.3/309.81
#60 0.5mg. clonazepam PO BID PRN for 300.02/300.23
#30 80mg. lurasidone PO QD CF for 301.83/312.30
#60 100mg. modafinil PO BID QD for 327.15/296.80
#120 150mg. pregabalin PO, two tables QAM, 1 tablet PM, 1 tablet QHS for 293.83/296.80
#30 0.5mg. alprazolam PO QD PRN for 292.84//309.81

According to yourself, you have dx's of:

bipolar type one 296.5
severe clinical depression 296.3
GAD 300.02
social phobia 300.23
adhd 314.9
bpd 301.83
impulse control disorder 312.30
PTSD 309.81
I'd like to add, based on your posts:
Amphetamine-Induced Mood Disorder 292.84
Hypersomnia Related to ... 327.15

Lithium is the best thing out there for it, but it's not fun doing blood tests and such. I'd consider it soon and your PDOC should have prescribed it to you *already*. It might help with a lot of your other dx's too. Lithium may treat your bipolar well. (296.5) I also hope that it, along with the other medications listed here, can help control your Borderline Personality Disorder and Impulse-Control Disorder.

D-amp seems to be doing well for you and I think the dosing control I suggest would be better for you since you play with your Vyvanse. D-amp seems to be doing alright for controlling your ADHD (314.9)

Imipramine (Tofranil) gold standard TCA, imo, and while not as good as say desipramine for ADHD -- it is one of the most underrated drugs out there. It seemed Prozac worked a little bit; I'm surprised your doctor hasn't tried a TCA yet. You'll be hard pressed to find someone who would know enough about imipramine to actually prescribe it, but I think you have a clear indication for it. Imipramine is a medium strong SRI and a strong NRI so you'll get some of the effects that the Strattera was going to do in addition to depression relief. it has nearly equal potency with regards to Serotonin and Noradrenaline + less sedative than clomipramine and not too stimulating like desipramine. It should be helpful for your Major Depressive Disorder (296.3) and is indicated off-label frequently for PTSD (309.81).

Clonazepam is one of the best psychotropic medications and it should definitely help your GAD (300.02) and Social Phobia (300.23).

Lurasidone would be my next pick of an AP to assist with Borderline Personality Disorder (301.83) and Impulse Control Disorder (312.30).

Modafinil I indicated for hypersomnia related to (327.15) bipolar (296.5); due to the drugs used to treat your conditions for that. It may help your ADHD, lots of good reports.

Lyrica (pregabalin); this would also help with the anxiety and it would act as a minor mood stabalizer. It is notorious for being a "mood brightener" as well. Also, there is a chance it could alleviate some of your pain problems. Great medication.

Alprazolam can be taken during d-amp comedowns which I think may be causing mood disorders (292.84) for you that some of the other drugs may help with as well. Also, if you're suffering a panic attack due to PTSD, it would help as well. Augments clonazepam well.

------------

Please, can anyone critique? I'm always open for this. It helps me out in a lot of ways.

 

[Geaux Tigers!]

Hey, I tweaked the above post a lot since posting it.

Please, can anyone offer advice or critique? Thanks.

 

[tokenname]

You seem to know what you're talking about..
it would silly of me to even try...


But I would like to critique whomever came up with the term "borderline personality disorder."

~token

 

[ErgicMergic]

Geaux Tigers, social anxiety is more a phobia, not an anxiety disorder. So, anything that will increase the chance of extroversion and exposure helps with that, including stimulants, and stimulant antidepressants (whatever you mentioned except for Paroxetine), and exposure therapy.

However, I believe GAD and PTSD are far worse than social phobia. After all, you can just not talk to people if you don't feel comfortable, but there's no escaping trauma or worry, even in your own home. I would fathom a guess that even the smallest amount of NE boost, like from SNRI's, or even from Strattera, could be making her anxiety worse. There's absolutely no reason she should take NE boosters. If she was inattentive ADD, she would have enough NE release naturally from her anxiety and trauma disorders, considering they were diagnosed properly and still pose a threat to her wellbeing today.

Also, Bipolar is extremely overdiagnosed these days, especially by newer pdocs, who don't want to leave the Axis II portion empty. If 140mg Vyvanse is not making you manic from a hypomanic state, I highly doubt that you have Bipolar. Even hypomanics can trigger mania with that much amp. I would not take Lithium, Lamictal, Depakote, or any other mood stabilizer unless absolutely necessary, same with neuroleptics. The side effects are almost as bad as the disorders themselves. Plus, they make you stupid, so there's no point of taking them on a regular basis while taking ADD medications at the same time. I would at least first reduce amps to 30-50mg Vyvanse and see if that helps mania/psychosis if you are indeed getting those while stimmed.

Are you seeing a clinical psychologist, Katie? You can't be pumping your brain full of all those nasty drugs and not get any behavioral therapy at least, maybe you won't need half of that crap after learning how to control anxiety through mindfulness and CBT.

 

[Geaux Tigers!]

Note, after rethinking it, I no longer suggested paroxetine in my latest post and at all and also Paroxetine is one of the more stimulating SSRIs. It has more NE reuptake inhibition than most. I believe 36% at 60% occupancy versus venlafaxine, respectably.
I also did not agree with a NE boosting medication; and in my pretend medication cocktail there is nothing beyond imipramine.

Social anxiety [phobia] is going to respond best to benzodiazepines; however, TCAs don’t necessarily attenuate the problem. A lot of with social anxiety respond well to SSRIs. Additionally imipramine has been proven to treat anxiety, including GAD (it does have a SSRI-like mechanism and it does a lot with NE) SA is a tougher monster and indeed more of a phobia, I know, which is why I why write benzos and hope that her stimulants and the modafinil (even Lyrica, you'd be surprised!) would help with that, like they do with a lot of people suffering from SA. I would mainly hope that imipramine would target her Major Depression and the things that go along with that. It has the potential to benefit a lot of her dx’s so I will stand behind imipramine being a respectable AD choice, especially if she had some sort of positive result to Prozac; she seemed to feel “helpless” based on her posts and I think imipramine would be indicated for that.

What are you talking about? Bipolar is an Axis I. I do not know any pdocs who rush to fill in an Axis II disorder, unless indicated. I’m not here to question the route of her dx’s. I’m more of a traditionalist and I would write medications based on her dx’s, obviously. Lots of bipolar patients are treated successfully with both a mood stabilizer and stimulant if they have concomitant ADHD. I think it’s wrong to make the presumption that the dx is wrong and what would cause mania. I’m not sure what judgment you can make regarding the effects of d-amp on her bipolar and the accuracy of her dx’s until she can provide us with some subjective information regarding this. I’ve said before that I’m not a fan of neuroleptics but it might be a good option with concomitant dx of BPD and Impulse Control Disorder if she doesn’t respond to a plethora of alternative medications. She said she did get some positive results from Abilify. I’m not why she has not been scripted a benzodiazepine; I’ve seen a lot of indications for these in her posts.

Yes, the way I see it is there are people who need these drugs and people who don’t need these drugs. I’m not sure about the chemical imbalance theory; more or less, these drugs are a chemical replacement for proven and more helpful therapies. Also, I think most psychotropic drugs are not good for your long-term health and cognition. Definitely seek professional psychological counseling. But in the context of psychiatric treatment and this thread, I am trying to give the best psychotropic advice I can give here. I don’t deal with anything else.

Katie, do you believe that your bipolar dx is appropriate?

 

[Shady Kaity]

I definitely am bipolar, I was diagnosed twelve years ago when I was 8.
If. Anything, it may be ADHD that's misdiagnosed..it was the most recent diagnosis of marked attention deficet. I had never been rxd meds for attention until this past december, and I mainly pushed for it since I. Just started college this january and really need to be able to focus and do well. I definitely agree with disliking APs due to the side effects, I wish I could have the mood stabilization. Minus the adverse effects, cuz I do really need it.
I've been in psychotherapy since the age of six.

I honestly don't remember if geodon was otherwise effective, its been four or five years since. And I only took the saphris twice...I'm pretty much having problems with everything but the attention deficiet now...I'm still depressed andanxious, extreme flucuations in mood, I have nightmares every single night for the last four years so I don't feel like I ever get real restful sleep.
Id just like to feel more balanced, just not as severe mood swings and love/hate swings or irritability. And too be able to feel at ease in my own skin sourroundings and around other people. And id like to get restful sleep.
I have anger issues, but over the last 6 months its been a little better, still not where id like it to be though.

 

[Alex000]

I think I would firstly, avoid that Stattera. Then I would do away with the Vyvanse (at least on a daily basis), and taper down and do away with the Cymbalta. I think what could really be of help to you would be a tricyclic anti-depressant. There are a number of these, some more initially sedating than others. They can work quite well with depression, anxiety, pain, sleeplessness, and attention issues. They work on serotonin and norepinephrine. I think at the right dose, a TCA might be of great help for you. I might also suggest Lyrica or Neurontin, and a benzodiazepine (either daily or as needed depending on how well the TCA and Lyrica/Neurontin controlled your anxiety). Just ideas to consider.

 

[Geaux Tigers!]

I definitely am bipolar, I was diagnosed twelve years ago when I was 8.
If. Anything, it may be ADHD that's misdiagnosed..it was the most recent diagnosis of marked attention deficet. I had never been rxd meds for attention until this past december, and I mainly pushed for it since I. Just started college this january and really need to be able to focus and do well. I definitely agree with disliking APs due to the side effects, I wish I could have the mood stabilization. Minus the adverse effects, cuz I do really need it.
I've been in psychotherapy since the age of six.

I honestly don't remember if geodon was otherwise effective, its been four or five years since. And I only took the saphris twice...I'm pretty much having problems with everything but the attention deficiet now...I'm still depressed andanxious, extreme flucuations in mood, I have nightmares every single night for the last four years so I don't feel like I ever get real restful sleep.
Id just like to feel more balanced, just not as severe mood swings and love/hate swings or irritability. And too be able to feel at ease in my own skin sourroundings and around other people. And id like to get restful sleep.
I have anger issues, but over the last 6 months its been a little better, still not where id like it to be though.

You haven’t tried out Lithium? I think it is the best drug for bipolar patients. It gets a bad rap but based on what I’ve read; you should definitely give it a shot! A good mood stabilizer can change a bipolar person’s life completely and could reverse a lot of your problems, especially with BPD.

Also, as I’ve suggested, you really need a benzodiazepine. I think it’d get rid of a lot of your anxiety and impulsiveness and help with your sleep. It might help you feel more comfortable around other people and with yourself. Additionally, I think the Lyrica would be good to try. It has anxiety reduction (indicated for GAD in Europe), anticonvulsant (thus mood stabilizing), fibromyalgia pain (may help out your weird pain) and I swear it is notorious for brightening mood. I believe that it is a better drug than benzodiazepines in my many respects.

My cocktail includes these things:

#60 900mg. lithium; PO, 1 tablet QAM, 1 tablet QPM for 296.5
#60 0.5mg. clonazepam PO BID PRN for 300.02/300.23
#120 150mg. pregabalin PO, two tables QAM, 1 tablet PM, 1 tablet QHS for 293.83/296.80
#30 0.5mg. alprazolam PO QD PRN for 292.84//309.81

I think that this is the way to go, immediately. As in next visit.

Also, if you look at the other things in my cocktail:

#90 10mg. dextroamphetamine sulfate; PO, two tablets QAM, 1 tablet QPM for 314.01
#60 100mg. modafinil PO BID QD for 327.15/296.80

^^ I know you said your ADHD is under control, if you even have it; I still like the dosage playing around you can do and the modafinil will really help with fatigue you may get from some of these medications.

#30 125mg. imipramine PO QHS for 296.3/309.81

This was what I was thinking for your depression for everything I talked about in my prior posts and the fact that it is in a drug category you haven’t tried yet. There still more options in the future. You can drop the ADHD meds/Cymbalta and try out the MAOI, Nardil. I think it might be better than anything else for you, honestly.

#30 80mg. lurasidone PO QD CF for 301.83/312.30

I hope a good mood stabilizer would help things out but if you still don’t have things under control, such as BPD, etc. You might need an AP and this is the one I would try next.

I’m glad you’ve been taking psychotherapy, that’s good. I’m not sure what ErgicMergic was intending with his input btw. Besides, this is a drug forum for the best psychotropic medications and for your dx’s; no sense in questioning them and all of that jazz.
I really hope you can get things to work out!