49 replies to this topic

[Tom_]

I suffered from sexual dysfunction late during and six months after treatment with SSRIs for about 1.5-2 years (Sertraline 150mg or 20mg escitolpram) and many other meds, including Mirtazapine, Quetiapine but always SSRI's. The dysfunction seems to be after mirtazapine discontinuation.

Came out of a 2.5 day Coma on Monday from suicide attempt. Long history of severe anxiety (much improved - phobic, obsessive, generalized not improved - social), neurodevelopmental disorder and learning disorder. My primary problem is Major Depressive Disorder with Dsythmia or double depression and long term sleeping problems.

I know venlafaxine is renown for causing sexual side effects - some claim the most severe.

The aim would be high/max dose of both within 12-15 weeks. I have a year history on mirtazapine at 45mg with mild treatment response.

Venlafaxine- long release 225-375mg and Mirtazapine 45-60mg (hesitant to go past the 45).

At doses like that I can take 1 at night for sleep and one in the morning to wake up.

What side effects do you see as likely?

Weight gain, loss or much the same? Sexual side effects, improvement, the same? Headache? Risk of psychosis? Suicidal behavior?

My hands may be tied but which would you start first? Mirtazapine or Venlafaxine.

Would you recommend (despite the evidence for rocket fuel) another SNRI or NaSSA? I know Duloxetine seems slightly more effective than Venlafaxine.

What would you recommend as a third and final medication if I am not a full responder (on the assumption I'm doing everything else 'right')? Options I'm considering are:

T3, Lithium, AAP (Amisulpride or Aripiprazole), Bupropion, Modafinil

[Reformed-Redan]

Hi Tom,

I'd stick with something that works and just stick with it. It may be something you have already taken in the past. I don't think mixing too many compounds is a good idea for keeping a balance between neurotransmitter levels.

Given the gravity of the situation (YOUR LIFE) I don't really have anything to say; however, you may want to look into lower levels of BDNF found in suicide victims. Found here. Here is a thread I made on a long list of substances increasing BDNF. I would miss your input on the forums. Heh.

This is also an awesome book you might want to check. Really worth it by all measures.

[Tom_]

Everything seems to be worse when I'm not on polypharmacy.

This excludes my first hospitalzation when I arrived on a multi vitamin, omega 3, Quetiapine (maybe?), Sertraline, Mirtazapine and methylphenidate. A month later I was somewhat stable on 30mg mirtazapine after being taken off everthing which I kept for about a year at 45mg, during this time I re-continued with Sertraline (150mg) Methylphenidate (60-160mg), Quetiapine (100mg).

Following discontinuation of Mirtazapine my next stablish point all be it with the lowest mood I've ever had was Escitlopram/Agomelatine, Lamotragine and Aripiprazole.

Having been on melatonin 3 mg and Agomelatine 50mg for the last 3-4 months with 1 month trial of buspirone (knocked me flat for some reason) I have become progressively more impulsive, suicidal & hopeless, although I've never had a direct negative reaction to melatonin. I'd describe myself as barely walking the line between sanity and insanity at the moment with time spent ether side.

It makes sense to be to re-start Mirtazapine or go for TCA/MAOI-a (Mecobromide) I can understand the P-Docs refusal although I disagree with it and would not do so myself - I had a psychopharmacologist assess me a few months ago before I became this bad and she recommended venlafaxine. My psychiatrist is a tool and will stick with her assessment anyway, I'm fairly sure he will insit on Venlafaxine. If this is the case if he doesn't allow dose esication weekly I'm outta there and looking for private practice.

I appreciate you giving a damn.

I've read the book thank you.

Yes the three most interesting things found in the dead by suicide is up-regulated 5HT2 receptors, decreased BDNF and reduced 5HT metabolite 5HIAA.

[focus83]

Hi Tom,

I'm shocked to hear about your suicice attempt. :( I sincerely hope you will make a full recovery from the coma!

Isn't it conceivable that you could receive ECT considering the graveness of your situation?Also what about an irreversible MAOI like Nardil, Parnate or Marplan?
I'd find it irresponsible of a psychiatrist to deny you access to these treatments when it's about life and death. I mean you've been hospitalized multiple times and now you even tried to commit suicide. How much more has to happen until you receive last resort treatments? You should do your utmost to receive them!

I just have the strong feeling you have pretty much exhausted all the commonly prescribed drugs and combinations thereof. It's very unlikely that Venlafaxine + Mirtazapine will all of a sudden be panacea for you given that you've been on both of them already with limited success.

[Tom_]

Thanks for the reply.

I haven't tried Venlafaxine...I don't hold much hope for it alone. In combo it has been shown twice to outperform tranyclobromide without meeting significance on symptoms but on tolerability.

Ect would be refused to me without any doubt and I don't think it is required. A true MAOI will also almost certainly be as well. I can't for see an agreement to prescribe any TCA other than lofepromine. I may be wrong and my psychiatrist will change his thoughts.

I would really like to try amitptyline, imipramine or trimipramine combined 4-6 weeks in with Meclobromide. The reversable MAOI-a.

A short version of what I've tried in various combos

3 SSRIs
Mirtazapine - best response although totally inadequate
2AAPs
Lamotragine
Agomelatine
Methylphenidate
Multiple nootropics

I dont expect to find a physical 'cure all', something to reduce symptoms would be great.

[Tom_]

If I'm allowed to choose my medication I think I'll start trimipramine and after 4-6 weeks if there is a severely inadequate response (the expected) I'll add Meclobromide.

The reason for this idea is because I would effectively be taking an Antipsychotic, TCA and Meclobromide...all be it with severely reduced noradrenlergic function from the potent antiadrengic effects of trimipramine, which is the only thing that turns it off about me as it has very mild SNRI effects unlike most TCAs.

The other option is the same but with Amitryptaline or Imipramine and then Meclobromide.

A similar option is Amitryptaline/Imipramine and Amisulpride.

[focus83]

Ect would be refused to me without any doubt and I don't think it is required. A true MAOI will also almost certainly be as well. I can't for see an agreement to prescribe any TCA other than lofepromine. I may be wrong and my psychiatrist will change his thoughts.

Whats the reasoning behind denying you all this? From what you wrote your conditions are as bad as they can get. To me it sounds like you THINK you would be denied all these, but do you really know for sure? Have you asked with vigor? I mean, you are the perfect example for a heavy treatment resitant case and even a blind psychiatrist should realize that. And why wouldn't they even prescribe you a TCA other than Lofepramine? That's beyond ridiculous. Something is seriously wrong with your psychiatrist or the medical care system where you live. Don't you feel completely let down?


Also why do even you think ECT is not required? But OK, if you definitely won't get ECT, what about TMS or TDCS?

With the options you are currently being offered, most likely nothing will work. They let you go round in circles. It's really sad to stand by and watch.

[Tom_]

Venlafaxine and Mirtazapine is about equal to effectiveness as any 1 single 'good' med I could be offered.

My psychiatrist (he is head of the research within my trust) and generally the mental health team where I live doesn't like using more than 2 drugs at the same time for the sake of being able to tell what's having an effect, what that effect is (improvement, worsening...nothing, in what areas etc), side effect control. I agree with this although I would extent it to four meds in utterly treatment resistant cases.

He is making a mistake but at the same time he is making an honest effort to 'wean' me off what he perceives as an unrealistic reliance and believe in medication into intensive behavioral activation and therapy. I am angry at him, fucking furious (although closest behavior and feeling I can summon up is a mild irritability) however he isn't medically negligent and he is acting as much with in an evidence base as me. My theoretical base is superior but I do have a respect for his dog eared refusal to bow to sensible sounding ideas without evidence.

I have had very poor continuity of care six psychiatrists (two working together) in about 2 years and a hospital psych. I then had to move services, my next psychiatrist left was was a fill in until I could see my planned one. She was very good but left for another country. This is often why I haven't been offered a step up to more dangerous meds because each psychiatrist wants to try another 'lower level' option or ten.

I have been let down by the system and it does disgust me (again the best I can summon is mild irritation).

ECT normally shouldn't be used until all reasonable drug trials have been tried, I am in immediate danger of attempting suicide (i.e. attempting multiple times in the space of 72 hours with anything within reach) or I am psychotic. rTMS is something I can buy but the evidence base is less for it than ADs. TDCS shares the same problems as rTMS.

I can't be sure what he will offer me but I remain fairly sure it won't be anything interesting unless I suggest it. In the five months I've known him I have been on Agomelatine until the general hospital have had to taken me off it after the attempt. 3mg of melatonin (self prescribed but aware) and I had month of buspirone which for some reason caused nasty side effects - I had to push for that.

I imagine his plan is for venlafaxine - following the pharmacists recommendation (strictly it was continue Agomelatine and try Venla, then wellbutrin and then lofepramine...if I still wasn't improving she would see me again). He may even want me to restart Agomelatine..which he will want to spend at least a month titrating up to normal dose, maybe two before I even start the venlafaxine. If this is his plan I won't stand for it.

[Reformed-Redan]

Have you asked ScienceGuy if he is willing to share some NSI-189 with you? Ask him. I doubt he'd refuse.

Do you take any illicit drugs as self medication? If so, I'd stop. Antipsychotics might sound like a good idea even though you don't sound psychotic on these forums. Most of your posts are coherent and make sense.

[Tom_]

I don't know what else to say but eh? Why would ScienceGuy give me some (sounds like a great guy - MDD sufferer himself?)/is it hard to get hold of? Isn't it in 1d trials or something? any idea of mechanism of action?

Sometimes I use cannabaloids/drink/smoke not with any regularity and not all that often.

I'm not psychotic, I've had some close calls to breaks always starting and resolving quickly (don't know what would happen if I crossed the line, whether it would resolve within a few days/weeks or be a full psychotic episode - although still likely short as related to affective disorder and quick onset).

I love the qualifier on there 'most' of your posts make sense.

Thanks,

Edited by Tom_, 17 June 2013 - 08:33 PM.

[Reformed-Redan]

I've heard bad stories about tapering off venlafaxine. It can be real hell. Remeron poops out fast which frustrates many people, afaik. Some older TCA's might work where first line treatment has failed you.

I don't know what else to say but eh? Why would ScienceGuy give me some (sounds like a great guy - MDD sufferer himself?)/is it hard to get hold of? Isn't it in 1d trials or something? any idea of mechanism of action?

Sometimes I use cannabaloids/drink/smoke not with any regularity and not all that often.

I'm not psychotic, I've had some close calls to breaks always starting and resolving quickly (don't know what would happen if I crossed the line, whether it would resolve within a few days/weeks or be a full psychotic episode - although still likely short as related to affective disorder and quick onset).

I love the qualifier on there 'most' of your posts make sense.

Thanks,

Well, I doubt anyone sound sane and rational all the time. That would rather be insane? Heh. NSI-189 sounds like it holds a lot of promise from what I've heard for MDD and hippocampal regrowth. Anyway best of luck to you.

[Tom_]

I cold turked 150mg sertraline without blinking an eye and came off four weeks 4-8 grams phenibut with little to no problem...every drug acts differently but if its all I'm offered I dont think I should let that stop me but thanks for the warning.

Forgot to mention I've abused phenibut and Benzo's but don't any longer.

Thanks, I'm looking into it now.

[focus83]

Venlafaxine and Mirtazapine is about equal to effectiveness as any 1 single 'good' med I could be offered.

On paper, maybe. The thing with an irreversible MAOI is that if your body chemistry agrees with it, then you won't find anything better. Nardil in particular has been a wonder drug and true life saver for so many patients who found no reflief from any other medication. Do everything you can to convince your psychiatrist to give it a try should the next couple of drug cocktails fail.

My psychiatrist (he is head of the research within my trust) and generally the mental health team where I live doesn't like using more than 2 drugs at the same time for the sake of being able to tell what's having an effect, what that effect is (improvement, worsening...nothing, in what areas etc), side effect control. I agree with this although I would extent it to four meds in utterly treatment resistant cases.

He is making a mistake but at the same time he is making an honest effort to 'wean' me off what he perceives as an unrealistic reliance and believe in medication into intensive behavioral activation and therapy. I am angry at him, fucking furious (although closest behavior and feeling I can summon up is a mild irritability) however he isn't medically negligent and he is acting as much with in an evidence base as me. My theoretical base is superior but I do have a respect for his dog eared refusal to bow to sensible sounding ideas without evidence.

I have had very poor continuity of care six psychiatrists (two working together) in about 2 years and a hospital psych. I then had to move services, my next psychiatrist left was was a fill in until I could see my planned one. She was very good but left for another country. This is often why I haven't been offered a step up to more dangerous meds because each psychiatrist wants to try another 'lower level' option or ten.

I have been let down by the system and it does disgust me (again the best I can summon is mild irritation).

So do you also think intensive behavioral acitvation and therapy is the key? If not, your psychiatrist is the wrong guy for you regardless of his position. In my experience, the higher the rank the more bone-headed they get. Don't let that blind you. Your furiousness towards him is not exactely an indicator for a working doc<-->patient relationship.

ECT normally shouldn't be used until all reasonable drug trials have been tried, I am in immediate danger of attempting suicide (i.e. attempting multiple times in the space of 72 hours with anything within reach) or I am psychotic. rTMS is something I can buy but the evidence base is less for it than ADs. TDCS shares the same problems as rTMS.

Don't let a weaker evidence base deter you. People respond to all sorts of random things when it comes to depression and sometimes even anxiety. If you can spare some money go ahead and try TMS or TDCS.

I can't be sure what he will offer me but I remain fairly sure it won't be anything interesting unless I suggest it. In the five months I've known him I have been on Agomelatine until the general hospital have had to taken me off it after the attempt. 3mg of melatonin (self prescribed but aware) and I had month of buspirone which for some reason caused nasty side effects - I had to push for that.

I imagine his plan is for venlafaxine - following the pharmacists recommendation (strictly it was continue Agomelatine and try Venla, then wellbutrin and then lofepramine...if I still wasn't improving she would see me again). He may even want me to restart Agomelatine..which he will want to spend at least a month titrating up to normal dose, maybe two before I even start the venlafaxine. If this is his plan I won't stand for it.

Your psychiatrist obviously lacks the creativity and open-mindedness to make a difference for you. It's really hard to give you any sound advise in a situation like that where you options are so limited. I would dump the guy at the earliest opportunity.

I suppose low dose ketamine infusions are not a viable option for you either?

What about Lyrica for better sleep or as adjunct to drugs that make you edgy?

Edited by focus83, 17 June 2013 - 10:11 PM.

[Tom_]

I forgot the pregabalin, I have tried that briefly. Only drug without argument I have never given a full trial to for any reason.

No I don't think its the way forward. In uncomplicated Severe sub-typed MDD chuck them an antidepressant and some cognitive therapy and see them a few times a year after recovery to ensure they are learning coping and recongnising skills and they will be fine. In my case where there is possible personality disorder, neurodevelopmental problems, seperate sleep issues and an almost total non-response to meds I think it makes a big part, give or take as much as the right med would (I can't be sure until I've tried a lot more, maybe I'm just leaving what I actually believe I'm so desperate to think something might work (therapy)).

We are very much antagonistic, I was told he was the best they had for difficult, hard to treat or impossible cases and he checks out as such. If he doesn't agree to something reasonable this time I'm out of there but I'm also aware if I keep swapping (first time its my choice) then I will never get any continuity of care. I guess the best we can do is wait for tomorrow, I never was very good at waiting.

Edited by Tom_, 17 June 2013 - 10:42 PM.

[Major Legend]

I think MAOIs and TCAs are definitely worth a shot, e.g. amitriptyline, you need to find a way to obtain those. Trying more types of similar drugs and compounding them is unlikely to produce a large change in result.

The mental healthcare in england basically really sucks, and we import too many foreign doctors who only care about getting paid by the government and as a consequence doesn't care about the patients.

[Tom_]

I do agree with you guys, its time to move to the heavy guns. However this is reasonable evidence that Mirtazapine is just as effective as amitriptyline. The problem in the study could be related to sub-typing of MDD not being taking into account.

I've found the non-medical care to be of good quality. There doesn't seem to be any standitised way for Psychiatrists to practice however.

[Babychris]

Don't go over 30mg of mirtazapine. You have to give a try to nardil I think it could be a panacea but don't give it all your hope in.

are you prone to irritability or angryness ? If not you could try selegiline though you can stack it with a dopamine agonist for sexual dysfunction..

Some other option are on my mind but I'm a bit moderate since you seem to be very desperate I don't want to give you stupid adivce.

[Tom_]

Right, seen the psychiatrist today. I don't think you guys will like it but I'm content (not ideal by a long way but happy to try it - for now).

I've been prescribed Venlafaxine 75xl. Each week I go up by 75 until week 3 (225mg). I am to continue with 50mg Agomelatine. My psychiatrist wants this to stay stable over three months (1 month to for dose titration and two too see effectiveness). This is the area I am not happy with. 3 months is to long if there is no effect. I will attempt to get him to swap for the mirtazapine at the second month (complaining of the almost certain sexual side effects and worsing insomnia as a reason to) and then at the third month(assuming he will only expect 6 weeks to gage if the combo is working)...He actually doesn't want to try mirtazapine and would rather an MAOI - meclobromide (we both agree this before irrervsable is best). He is open to TCA therapy as well.

I will be starting DBT therapy (the one to one sessions as soon as possible, I don't have access to the group side (1-4 weeks I'm guessing)), I'm to carry on trying to occupy my time and la de da.

Its not ideal but its an evidence based and perfectly reasonable approach (excluding the three months which should be two).

[Reformed-Redan]

Sounds good. Remeron might work and poop out. Kind of frustrating from what I've heard. Nardil isnt something you just decide one day to take. Its probably the most potent drug in the psychiatric arsenal and is double edged with strong side effects.

[8bitmore]

[...]
I suppose low dose ketamine infusions are not a viable option for you either?
[...]

I second that the use of Ketamine is a completely good idea, there's quite a lot of research and people who respond to it responds really really well and only require occasional re-dosing. If you can not get a doctor approved dosage there's even analogues out there..

[focus83]

Fantastic news. Not necessarily the Venlafaxine, but the fact that your pdoc doesn't outright dismiss TCAs and MAOIs. Of course it's sensible to try a reversible one first, but a poor response to a reversible MAOI is not indicative of how you would respond to an irreversible MAOI.

Things are progressing All the best for you. Keep us updated.

[Tom_]

The response to tranny and Meclobromide are within the same level of significance on every study I've read. Never more than 8% apart.

I had the venla as soon as I got it - going to be taking it in the morning. It feels fucking fantastic, I forgot what having serotonin feels like. I don't like to admit it, even more so because I don't really like the man but I think he is right, the venla needs to be tried. Not for as long as he recommends but hey, what can you do?

Hopefully it will make it endurable until I can switch to a better drug - a fair assumption is I'll need to.

Guys I can't tell you all how much I appreshiate all the effort you have put into well thought out suggestions. Most of you that know me, know when/if I'm being rude its either because I am in a place where I'm no longer able to tell the difference or because I'm trying to inspire more thoughts...which maybe isn't an excuse. Either way I'm sorry and thanks. You have all been a great help.

[focus83]

The response to tranny and Meclobromide are within the same level of significance on every study I've read. Never more than 8% apart.

Take it for what it is: statistcis. Doesn't tell you much about your own response. It would be foolish not to try irreversible MAOI when a reversible fails. Especially Nardil is probably your best bad because it raises GABA levels as well.
Tranylcypromine might easily be too overstimulating. If that happens I would combine it with Lyrica or even better with Baclofen to take the edge off it. In my own experience Baclofen is unbelievably good for smoothing anxiety and jitteriness from e.g. amps or MPH. Much better than beta blockers or even benzos.

Guys I can't tell you all how much I appreshiate all the effort you have put into well thought out suggestions. Most of you that know me, know when/if I'm being rude its either because I am in a place where I'm no longer able to tell the difference or because I'm trying to inspire more thoughts...which maybe isn't an excuse. Either way I'm sorry and thanks. You have all been a great help.

Nah, you never came across as rude.

[Alpha_Master]

Hi Tom,

I can somewhat understand what you are going through. What worked very well for me was telmisartan. It is a medicine used to treat hypertension but has amazing anti-depressive properties under my experience. I would suspect any sartan class drug would induce a similar response. The side effects at the dosage (20-40mg) I took were minimal if not "pro" effects on mood and skin tone. Though I doubt this drug is something your doctor may be comfortable prescribing, you ought to give it a try. The mood lift is not a "high" you get for a couple hours but just a reduction in hopelessness, frustration, and stress. I believe these are the stress hormones being blocked which also add to the anti-hypertensive action of the drug..?

Angiotensin II, through AT1 receptor stimulation, is a major stress hormone, and because (ARBs) block these receptors, in addition to their anti-hypertensive effects, may be considered for the treatment of stress-related disorders.<sup>[8]

Sartan drugs are ARBs.</sup>

[Tom_]

My psychiatrist also recommend I go back to see the private sleep neuropsychiatrist I visited a few times. It looks like his next move is going to be to prescribe Modafinil. So I may find myself on:

Venlafaxine, Modafinil, Agomelatine.

[gavino]

First things first: don't take all these pseudo-psycho-pharmacological treatment suggestions from the many interweb users. They/we mean well, but we are not by any means a doctor.

IMHO, putting all one's faith into one of the numerous novel non-monoaminergic pharmaceuticals in the pipeline doesn't really lend itself to getting through a MDD episode. If you can get into a trial, great, do it. Otherwise, all I would suggest, from experience, is to try and get into a research university. It's important to be around people who are up to snuff with all the goings on in the science world w/r/t psychiatry. Or, they will be the most up-to-snuff you can find. And, considering you frequent this type of website, you likely think you are very knowledgeable about what's what w/r/t pharmaceutical solutions to psychiatric problems. At least, I did, and it has been important for me to not just print up a study from PubMed and bring it into my GP to try and convince him to prescribe me something that isn't a well known treatment for depression because it has very little data to back it up (e.g. when everybody was going nuts over memantine 2-3 years ago...). Also, cost-wise, they have worked with me much more than any insurance company has.

Within the past 2 years, I was on the same California rocket fuel program as yourself. The blackhole I got sucked into after it 'pooped out' on me was terrible enough to get me to the [PA Ivy League Psych Out Patient Services]. After trying all different stuff for legitimate 4-8 week trials (which I would have never put up w/ had I been going to a GP), I've found some success on a 2nd (?) generation TCA. Basically, by monitoring my bloodlevels of the TCA, my psychiatrist noticed that they were always very very low. I would end-up having to get my blood drawn again to make sure there was no error. They are now claiming me to be a CYP2D6 "ultra-rapid metabolizer". This makes sense subjectively, w/r/t my experience with the effects of substances like caffeine, alcohol, nicotine, etc. 'not lasting as long as it should'. I will be getting a genetic test (cheek swab?) done next time I go in for my appointment (supposedly only $20). Since this observation, we have steadily increased my TCA dosage to where my blood levels were coming back in the desired range. The past 3 weeks or so, I have been quite euthymic (which, you know, is sort of the goal). After 10 years of psych treatment for MDD, it is relieving and ironic to recognize the simplicity of a major cause of my 'treatment resistance'. Maybe some of this was remotely helpful.

[Killword]

I also have double depression with some social anxiety and ADD and a lot of sleep issues. Are your MDD symptoms more melancholic or atypical? Melancholic depression tends to respond well with TCAs whereas atypical depressives usually have very negative reactions to TCAs and respond best to MAOIs. I'm atypical and nothing short of ketamine worked as well as Parnate and Nardil for me. If you decide to go that route I suggest checking dr-bob.org for the latest info about MAOI diet and drug interactions--it's really not hard to follow and many things like mozzarella cheese/pizza have actually been found to be quite safe to eat.

Venlafaxine+Mirtazipine does seem interesting and might be a better first choice (I think it has been shown to be nearly as effective for treatment refractory depression as Parnate in one study). I think the side-effects of the Mirtazipine (sedation, weight gain) are supposed to be less of an issue with the combination but I'm not sure. I found Duloxetine much more anxiogenic than venlafaxine, fwiw, and had most of the obnoxious SSRI sides from it.

Moclobemide might help, too, I would be very interested to hear how well it works if you decide to try it.

Low dose amisulpiride is supposed to be good for dysthymia, I would personally choose that over abilify or any other neuroleptic. unless they helped you in the past, of course, but for me they just made me lazy and dead tired all the time. Totally destroyed my sleep patterns as well. Obviously they are indispensable in certain situations but if you don't have any manic, psychotic or ruminative issues they might not be worth the potentially serious side-effects.

I suffered from sexual dysfunction late during and six months after treatment with SSRIs for about 1.5-2 years (Sertraline 150mg or 20mg escitolpram) and many other meds, including Mirtazapine, Quetiapine but always SSRI's. The dysfunction seems to be after mirtazapine discontinuation.

Came out of a 2.5 day Coma on Monday from suicide attempt. Long history of severe anxiety (much improved - phobic, obsessive, generalized not improved - social), neurodevelopmental disorder and learning disorder. My primary problem is Major Depressive Disorder with Dsythmia or double depression and long term sleeping problems.

I know venlafaxine is renown for causing sexual side effects - some claim the most severe.

The aim would be high/max dose of both within 12-15 weeks. I have a year history on mirtazapine at 45mg with mild treatment response.

Venlafaxine- long release 225-375mg and Mirtazapine 45-60mg (hesitant to go past the 45).

At doses like that I can take 1 at night for sleep and one in the morning to wake up.

What side effects do you see as likely?

Weight gain, loss or much the same? Sexual side effects, improvement, the same? Headache? Risk of psychosis? Suicidal behavior?

My hands may be tied but which would you start first? Mirtazapine or Venlafaxine.

Would you recommend (despite the evidence for rocket fuel) another SNRI or NaSSA? I know Duloxetine seems slightly more effective than Venlafaxine.

What would you recommend as a third and final medication if I am not a full responder (on the assumption I'm doing everything else 'right')? Options I'm considering are:

T3, Lithium, AAP (Amisulpride or Aripiprazole), Bupropion, Modafinil

[xks201]

Check your testosterone igf1 and thyroid levels and please stop relying on serotonin drugs which will only make you feel worse. Psychiatrists only look at one side of mental health. They ignore hormones. They are in general idiots.

[Tom_]

Thyroid is fine, I keep telling people testosterone disorders without other symptoms (like small balls) won't cause major mood disorders. The same goes for all other hormonal disorders. However they MIGHT contribute (ex: 1 in 10 psych admissions have an undiagnosed physical disorder that MIGHT contribute to there psychiatric problems, although this can range from epilespy to cancer).

Serotonergic drugs have again and again proved their worth in treating depression. There is a massive body of incontrivtable evidence (in nearly all major disorders serotonin is involved) for pathology in the brain for mental disorder and some (in cases very strong) for the HPA axis. The support for gonadal involvement in men is poor. Supplemeting with testosterone or cortisol (or antagonists) can lead to serious complications much more often than an SSRI or MAO-I, both with physical and behavioual ramifications (heart attack, aggression...).

All that being said Hormone pannels do have their place in Psychiatric evaluation (as well as other labs) and nearly all psychiatrists don't make use of them as much as they could. However in nearly all 'pure' psychiatric cases there only value is in guiding most effective treatment and estabilsing diagnosis (and/or its sub-classifcation).

[Tom_]

An update.

1 week and 2 days on venlafaxine at 150mg for last two days, I'm taking 3mg melatonin a night as well as 50mg of agomelatine. No obvious improvement in mood, maybe slight increase in obessional symptoms but would still regard them in the mild catagory but now pushing moderate. Impotentence has set in and I have a nearly constant chronic but very mild headache. I'm sure the venla is causing the cock problems but the headache could be the result of my shoulder injury, potensity towards mirgains and I imagine a shit ton of stress hormones floating about. Blood preassure was just checked and I'm within range with no significant change from last measurement.