[claireunderwood]

When the medical concern is something like GAD and it's known there isn't a chance of something like bipolar (since obviously those factors can affect med decisions) is the doctor left to essentially just do a "trial and error" thing? For the purposes of this question, let's say also that you're just starting antidepressants or have only tried one so there isn't really a "seems to react badly to X class" or anything like that yet. Because these meds affect people so differently, it seems the only thing the doctor can really do is go based on what he has seen or learned in his practice about what seems to be generally tolerated/effective in determining what would be the best one to try initially and then move from there (changing doses, trying other things, etc.). Or are there other factors?

For example, when deciding between, say, Lexapro, Celexa, Zoloft, Effexor, etc. are there truly criteria the doctor can use to say "okay, X will probably be more effective" until it's actually been tried? Or that I can use to try to determine that for when I see my doctor?

[Altered Moment]

In the case of GAD there are a couple of SSRI's that are known to be better. Paxil is one. The SNRI's probably not. In my opinion the SSRI's and SNRI's are not very effective for anxiety. Some people do have success with them for anxiety.

When it is for depression your guess is as good as the doctors. He has no way to know what might be better or not. After trial and error you might discover, like in my case, that SNRI's work better for you.

There is one new tool that is starting to be used that does a genetic test for what liver enzymes you produce. We all metabolize things differently. The test can show that out of 12 antidepressants which ones you will metabolize most efficiently. If you don't metabolize one well it will have more side effects. So they are rated green, yellow, and red. Better metabolism might mean better effectiveness but not for sure.

From everything I have read antidepressants will only work in 40 to 60% of people and probably after trial and error. It is not known why but is probably due to genetic sub types.

For instance they are more dangerous for teens and they have now identified genetic markers that tell them which sub types are much more likely to become suicidal on them.

I believe there are some more tests available now but I would have to look them up again. More and more will become available. it will be a matter of what insurance covers and how fast they are adopted by the psychiatric community. Psychiatrist will want to adopt them because they don't like it being a guess. But costs are always a factor.

You also need to be aware of possible withdrawal effects when stopping one or switching. From what I understand this is in about 20% of people. Switching means much less chance of withdrawal. You want to taper off the old one very slowly. Docs usually do this to fast. Start the new one and taper up at the same time you are slowly tapering down the old.

You for sure want to have your thyroid levels checked and this is common practice but make sure they do it. Vitamin D deficiency can cause depression. There are genetic polymorphisms (defects) that effect folate and L Methylfolate which can cause problems for neurotransmitter synthesis. You can take vitamin D, B vitamins, Fish oil, L theanine, and Melatonin as they are cheap and can't hurt and might help. L Methyfolate (Deplin) is prescription only and costs about $120 a months. So you would really want to know whether you have that genetic polymorphism or not. If you don't why take it. I am looking for a test for that now. There might be one available. Some other tests I have recently heard of and can find out more about because someone here is going to have them done and has figured out the costs. The costs don't seem to be unreasonable.

[Altered Moment]

The metabolism green, yellow, red genetic test -

GeneSight®

[AncientMelody]

Depends on the doctor. But some factors: Lexapro/celexa tend to be gentler with regards to start up side effects so may be given to someone whose particularly sensitive. Prozac is one of the more stimulating SSRIs in general so might be a good choice for someone who is very fatigued. It also has a long half life which can ease discontinuation. Paxil and Zoloft have more data than the others on PTSD so may be a factor there though Paxil is harder to come off of than the other SSRIs.

SNRIs can be good for comirbid fibromyalgia or other chronic pain conditions, my psychiatrist prefers Cymbalta over Effexor.

[claireunderwood]

Originally Posted by zinco14532323

In the case of GAD there are a couple of SSRI's that are known to be better. Paxil is one. The SNRI's probably not. In my opinion the SSRI's and SNRI's are not very effective for anxiety. Some people do have success with them for anxiety.

When it is for depression your guess is as good as the doctors. He has no way to know what might be better or not. After trial and error you might discover, like in my case, that SNRI's work better for you.

There is one new tool that is starting to be used that does a genetic test for what liver enzymes you produce. We all metabolize things differently. The test can show that out of 12 antidepressants which ones you will metabolize most efficiently. If you don't metabolize one well it will have more side effects. So they are rated green, yellow, and red. Better metabolism might mean better effectiveness but not for sure.

From everything I have read antidepressants will only work in 40 to 60% of people and probably after trial and error. It is not known why but is probably due to genetic sub types.

For instance they are more dangerous for teens and they have now identified genetic markers that tell them which sub types are much more likely to become suicidal on them.

I believe there are some more tests available now but I would have to look them up again. More and more will become available. it will be a matter of what insurance covers and how fast they are adopted by the psychiatric community. Psychiatrist will want to adopt them because they don't like it being a guess. But costs are always a factor.

You also need to be aware of possible withdrawal effects when stopping one or switching. From what I understand this is in about 20% of people. Switching means much less chance of withdrawal. You want to taper off the old one very slowly. Docs usually do this to fast. Start the new one and taper up at the same time you are slowly tapering down the old.

You for sure want to have your thyroid levels checked and this is common practice but make sure they do it. Vitamin D deficiency can cause depression. There are genetic polymorphisms (defects) that effect folate and L Methylfolate which can cause problems for neurotransmitter synthesis. You can take vitamin D, B vitamins, Fish oil, L theanine, and Melatonin as they are cheap and can't hurt and might help. L Methyfolate (Deplin) is prescription only and costs about $120 a months. So you would really want to know whether you have that genetic polymorphism or not. If you don't why take it. I am looking for a test for that now. There might be one available. Some other tests I have recently heard of and can find out more about because someone here is going to have them done and has figured out the costs. The costs don't seem to be unreasonable.

Thank you! This was a fascinating and very informative response. I haven't heard of this metabolism test yet. I wonder if it is available here in Canada yet (even if not covered by provincial insurance, I wonder if it is available for OOP, though that could be cost prohibitive even if it is). Regarding liver metabolism, I am someone who finds that many meds don't affect me the way they do others. For example, I seem to need higher doses to feel effects than others (I am more thinking of benzos and painkillers - taken only when prescribed - than ADs. I saw someone else comment that their doctor told them it had to do with the way their liver metabolized meds and I thought this was fascinating. I wonder if this is the case for me.

I bolded a few parts of your comments because I wanted to ask you about them. IYE/IYO why are SSRI/SNRI not effective for anxiety? What have you found better in this case?

Your point about switching medications (tapering up the new while tapering down the old) is really interesting as I've never heard this before (but I've never switched meds before); when the time comes (soon) I will see if my doc suggests this and if not ask him about it.

Thank you!!

Originally Posted by zinco14532323

The metabolism green, yellow, red genetic test -

GeneSight®

This sounds really interesting. Thank you for the link!

Originally Posted by AncientMelody

Depends on the doctor. But some factors: Lexapro/celexa tend to be gentler with regards to start up side effects so may be given to someone whose particularly sensitive. Prozac is one of the more stimulating SSRIs in general so might be a good choice for someone who is very fatigued. It also has a long half life which can ease discontinuation. Paxil and Zoloft have more data than the others on PTSD so may be a factor there though Paxil is harder to come off of than the other SSRIs.

SNRIs can be good for comirbid fibromyalgia or other chronic pain conditions, my psychiatrist prefers Cymbalta over Effexor.

Thanks! Lexapro was the one my doctor had me start on. It's the first and only AD I've tried so far, but he also indicated that it tended to have fewer side effects and I did find this the case for me. Curious as to what he will suggest when I switch.

[Altered Moment]

In my opinion the SSRI's and SNRI's are not very effective for anxiety. Some people do have success with them for anxiety.

This is my opinion based on my experience, the experience of people I know personally, and what I have read here and in other places. Some people say the SSRI's work great for them for anxiety. Benzo's are known to be highly effective for anxiety for the vast majority of people. I think the difference is they act on totally different biological processes and different cell receptor. You should be aware of the dangers of benzo's. We have had many discussions here about it. See this most recent one-

http://forums.psychcentral.com/psych...edication.html

There is one new tool that is starting to be used that does a genetic test for what liver enzymes you produce. We all metabolize things differently. The test can show that out of 12 antidepressants which ones you will metabolize most efficiently. If you don't metabolize one well it will have more side effects. So they are rated green, yellow, and red. Better metabolism might mean better effectiveness but not for sure.

Even if Canada doesn't cover that test I am sure you and your doc could do it if you paid for it privately. I can't remember what it costs. I to have a high tolerance to just about all drugs. I think it means we metabolize them faster and get rid of them faster. They would have a shorter half life with us so we may need a higher dose.
In the not to distant future I thing we will see much better drugs and they will test genetic metabolism along with other genetic sub types that will tell them what type of drug will work better for us individually. Sooner rather than later I hope but who knows. Lots of research going on now.

Start the new one and taper up at the same time you are slowly tapering down the old.

That is how they do it in the states. That is how they have always done it with me. I guess in the UK they make you get totally off the old before starting the new. I think starting the new right away would help prevent possible withdrawal from the old but that is my guess. Personally I have never had any trouble with withdrawal.

So I am guessing the Lexapro has not been effective for you for depression? or anxiety?

[Moogieotter]

Some great info in this thread. I'd like to add that my doctor asks about relatives, particularly sibling and parent use and experiences w SSRIs/SNRIs to help choose the initial strategy.

Let us know how it works out!

moogs

[kiwi33]

I can not speak for other countries but in Australia most GPs know very little about mental health issues.

That is a comment, not a criticism (I teach medical students in their pre-clinical years and GPs are, by definition, generalist primary health care providers).

My preference would be to get your GP to refer you to a psychiatrist. As a specialist, a psychiatrist will be able to do a proper assessment of you (for GAD, MDD, etc) and then, depending and drawing on his/her clinical judgement and experience, suggest a SSRI/SNRI which might best meet your needs.