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brainfog
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Default Aug 13, 2021 at 01:38 PM
  #1
Hi there,
I'm trying to find a good med for major depression. I've been on Prozac (20mg) and Wellbutrin (75mg) for two months. The Prozac is bringing a nice calming effect but my head feels almost dizzy-like all day. The WB works pretty good but I have trembles with it.

I really need calm and drive/motivation but I can't be all hopped up. This combo worked well for a couple of weeks but now I feel slow and heavy.

Questions or suggestions?
Thanks!
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Default Aug 13, 2021 at 01:46 PM
  #2
Can't say anything about best, but I was just prescribed Prozac and will be on 20mg for 2 weeks and then moved to 40mg, maybe more if needed. If you've had the same doses for 2 months, maybe you just need to adjust them. Maybe?

Edit: From your post history it looks like you've tried a few things, including higher doses of Prozac. I guess I have nothing else to offer then. Sorry.

Last edited by Anonymous40506; Aug 13, 2021 at 04:34 PM..
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Default Aug 18, 2021 at 05:22 AM
  #3
I'm on Lexapro and find it gentler if that makes sense than Prozac or Zoloft or Paxil. But it's very much an individual experience.
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Default Aug 24, 2021 at 12:07 PM
  #4
Been through a lot of them...Lexapro, Effexor, Wellbutrin and some others...had some success with Cymbalta, but the withdrawal from that was rather awful. Were it not for the weight gain, I might still be on Cymbalta...but as others have noted, it really is an individual experience.
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Default Aug 26, 2021 at 01:51 AM
  #5
Quote:
Originally Posted by brainfog View Post
Hi there,
I'm trying to find a good med for major depression. I've been on Prozac (20mg) and Wellbutrin (75mg) for two months. The Prozac is bringing a nice calming effect but my head feels almost dizzy-like all day. The WB works pretty good but I have trembles with it.

I really need calm and drive/motivation but I can't be all hopped up. This combo worked well for a couple of weeks but now I feel slow and heavy.

Questions or suggestions?
Thanks!
If you dont mind me asking, what is your diagnosis? Is it MDD? Bipolar? Clinical depression or a mood disorder?

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Default Aug 27, 2021 at 12:44 AM
  #6
Have you tried Rexulti? It can be used as an add-on treatment to antidepressant medication. It's a pretty new drug. It was introduced onto the market in 2015.
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Default Aug 27, 2021 at 02:55 AM
  #7
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Originally Posted by 185329 View Post
Have you tried Rexulti? It can be used as an add-on treatment to antidepressant medication. It's a pretty new drug. It was introduced onto the market in 2015.
Is this a mood stabilizer or antipsychotic?

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Default Aug 27, 2021 at 11:22 AM
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Rexulti is an antipsychotic. I take it for psychotic symptoms but it can be used as an adjunct to antidepressants. My experience with Rexulti though is that it made me gain a lot of weight. It works good though.

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Default Aug 27, 2021 at 04:50 PM
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Pristiq has helped me with depression.

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Default Aug 27, 2021 at 04:58 PM
  #10
Trintellix and cymbalta (duluxotine) mixed have been good for my depression. At least until recently. Now I don't think they are working so good but I see the Pdoc on Wednesday.

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Default Aug 30, 2021 at 07:59 AM
  #11
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Originally Posted by sarahsweets View Post


If you dont mind me asking, what is your diagnosis? Is it MDD? Bipolar? Clinical depression or a mood disorder?
I have major depression. Anxiety is a big issue! I'm currently on 60mg Proz and 75mg Wellbutrin. The problem is I have no go! I feel much calmer than I have in the past but motivation is terrible!

Many thanks for any thoughts!
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Default Sep 15, 2021 at 02:10 PM
  #12
Prozac is probably one of the better SSRIs for people who have problems with motivation. It looks though like you went from 20 mg to 60 mg in just a matter of weeks, which can be problematic. If you're not having any issues with it, though, then nothing to worry about. (Most other SSRIs tend to actually worsen this problem because increased serotonin will actually blunt the release of dopamine and norepinephrine in the brain. Prozac increases both dopamine and norepinephrine and Zoloft increases dopamine unlike other SSRIs.)

Wellbutrin is great for lack of motivation because it works on dopamine and norepinephrine. However, it's usually a pretty terrible choice of medicine for people who have severe anxiety (especially if the anxiety is worse than the depression). 75 mg is an incredibly low dose for Wellbutrin, even as an augmenting antidepressant. There are two things you could do, though.

1. The 75 mg only comes in an instant-release tablet. There are two extended-release versions of Wellbutrin: the sustained-release (Wellbutrin SR), which you take twice a day (once in the morning and once in the afternoon), and the extended-release (Wellbutrin XL), which you take only once in the morning. The instant-release version has quicker peak blood levels and exits your system quicker, which might lead to more anxiety/worse tremor than the two extended-release versions. The SR and XL versions have smoother action in your system than the instant-release, so perhaps switching to one of them would lead to less anxiety/tremor, and would help more with your anergia/lack of motivation.
* The SR tablet comes in 100 mg, 150 mg, and 200 mg.
* The XL tablet comes in 150 mg and 300 mg, and there is a proprietary brand name, Forfivo XL, that comes in 450 mg as an XL tablet.
* There is another proprietary brand, Aplenzin, which is the hydrobromide salt of bupropion (Wellbutrin and Forfivo are all the hydrochloride salt); supposedly the hydrobromide salt has an even better and smoother extended release mechanism than the hydrochloride salt versions. Aplenzin comes in a 174 mg tablet (equivalent to 150 mg Wellbutrin), 348 mg tablet (equivalent to 300 mg tablet), and 522 mg tablet (equivalent to the 450 mg Forfivo tablet).
* Insurance tends not to want to cover the Forfivo XL and Aplenzin, so if you go that route, you will likely need your doctor to do a prior authorization to get your insurance to cover it.
* The starting dose of Wellbutrin is typically 150 mg/day (either as one SR 150 mg in the morning, one 150 mg XL tablet in the morning, or one 174 mg Aplenzin tablet in the morning).
* The target dose is typically 300 mg/day, which you can go up to after a minimum of 3 days with the SR version (divided in two doses), or after a minimum of 4 days with the XL version and Aplenzin (348 mg).
* The max dose is typically 400 mg/day for both instant-release and the SR version, and 450 mg/day for the XL version (522 mg for Aplenzin).
* Usually you won't go up to 400 mg/450 mg/day with Wellbutrin as an adjunct agent, but some people do need this dose even with another antidepressant. Also, if anxiety and tremor are a problem in lower doses, it might not be a good idea to go this high.

2. Another option is to switch the Prozac to either Zoloft (another SSRI but also increases dopamine), or switch to an SNRI (Effexor XR, Cymbalta, Pristiq, Fetzima). When switching, you could perhaps try dropping the Wellbutrin and see how you do. The SNRIs increase norepinephrine, but also indirectly increase dopamine specifically in the frontal cortex, which is the area responsible for executive function.

3. An option that your doctor may be less likely to agree to try, you could switch the Wellbutrin for an actual stimulant. The stimulants (Ritalin, Adderall, etc.) are much better at improving symptoms like lack of motivation than Wellbutrin is and are less likely to exacerbate anxiety and tremor (especially the amphetamine-based stimulants like Adderall/Adderall XR/Mydayis, Dexedrine/Zenzedi, Evekeo, Vyvanse, etc.) Assuming your doctor gives you the okay, starting at a lower dose than is typically used for ADHD (like 2.5-5 mg/day Adderall/Dexedrine/Evekeo, 5-10 mg/day Ritalin, 10 mg Vyvanse, etc.), you could gradually increase the dose in tiny increments every few weeks until you feel your "sweet spot" (just the right amount of stimulation without being excessive). This is likely to be a lower dose than is typically used for ADHD. This is more easily done with the instant-release versions of these stimulants because you can split them in half or even quarters (Ritalin usually isn't scored so you'd need a pill splitter, but Adderall, Evekeo, and usually Dexedrine, are scored, usually in quarters).
* If you have very good rapport with your doctor and they trust you, they may actually offer to prescribe you enough of the smallest dose available of whatever stimulant you try to reach a certain dose (which you may or may not actually need) so that you can more freely find the right dose for you without having to check in more frequently with them. For example, if you were trying Adderall, your doctor may prescribe you 120x 5 mg tablets, and they may instruct you to start with the lowest possible dose, like 1.25-2.5 mg twice daily, and increase in the smallest possible increment, like 1.25-2.5 mg/day (or even 5 mg/day if you're feeling comfortable, which is typically how the dose is increased) every week (or however often they tell you). If you reach 20 mg and still feel you need a higher dose, they may then prescribe you enough for 40 mg/day, and you could continue titrating up in that same manner. When you find the right dose, at your next visit, your doctor would want you to let them know what it was/how you're taking it so they can prescribe the corresponding dose of tablet (so you're not taking lots of 5 mg tablets at once). For example, if you reached 25 mg/day, and this felt like the perfect dose, they could prescribe you 60x 12.5 mg tablets to take twice daily, or even switch you to Adderall XR 25 mg capsules so you only have to dose once daily, which would also feel much smoother (and, if you are having a hard "crash" at the end of the day which some have with instant-release stimulants, it would help with this, too; however, this tends to be less of a problem with the amphetamine-based stimulants then the methylphenidate/Ritalin-based stimulants).
* However, even if your doctor knows you well and trusts you, they may still want to more closely monitor your titration of a stimulant (especially since anxiety is a major problem with you, and while these stimulants tend to be less anxiety-provoking than Wellbutrin, it's still possible they can increase anxiety; however, it's just as likely that they can actually decrease anxiety, though this is more typical of people who have a very severe deficiency of dopamine and/or norepinephrine, as in most ADHD patients). What your doctor may do might be similar to the aforementioned fashion, where they would prescribe you enough small dose tablets to get to a certain dose, but, for example, instead of 120x 5 mg Adderall to get to 20 mg, they may prescribe you two week's worth of enough Adderall to get to 10 mg/day and instruct you to start as low as possible (1.25-2.5 mg twice daily) and increase in tiny increments as above (or however they instruct you to increase). So they may want you to have more frequent visits while the two of you are figuring out the right dose for you, and after you reach the right dose, they would have you resume seeing them as you previously were seeing them.
* With a stimulant being a Schedule II substance, you will have to visit your doctor every 30 days for a new prescription. But after a while, your doctor may do what my general doctor did and go ahead and fill out two or three prescriptions for the next two to three months, and write on the prescriptions "to be filled on or after [whatever date]." My new pdoc actually e-scribes my meds (not sure how she manages to do that with stimulants because I thought you couldn't do that with Schedule II substances...). I see her every 8 weeks, so she e-scribes two at a time, one to fill now, and when I need my second fill, I just call the pharmacy and ask them to fill the second one.

4. An option you may want to reserve as your last option is adding an atypical antipsychotic (someone here has already suggested try adding Rexulti). The reason I say you may want to reserve this last is because many antipsychotics have a long list of side effects such as weight gain, increased blood sugar and impaired glucose metabolism (and diabetes in the long term), increased cholesterol, increased triglycerides, etc. The ones I'm going mention either almost never or usually don't have these side effects, but it's always possible that they could occur. Antipsychotics, though, depending on which one, can help with both anxiety and issues with motivation.
* Abilify: This is approved as an add-on to an antidepressant in major depressive disorder. It usually is quite stimulating (as opposed to sedating like most other antipsychotics), especially in the lower doses (it may even out in the mid to high doses and be somewhat calming), and is usually quite weight-friendly and metabolically friendly. Initially, you may actually feel a bit too stimulated, and may even experience a symptom called akathisia, which basically feels like an extreme inner restlessness that causes you to move constantly and feel like you can't stop moving--you may pace around constantly, rock back and forth while seated, or feel like you have to shake your arms. If you try to stand still, you may actually shuffle your feet as though you're walking in place. While this side effect can be alarming, it's temporary. If it lasts longer than a few days and becomes problematic, you can either decrease the dose, or, especially if you're already at the lowest dose (2 mg), your doctor can add on an anticholinergic like Cogentin or Artane temporarily to help alleviate the akathisia. Abilify tends to not be a major offender of this side effect, but it happens more often with it than some of the more sedating antipsychotics, and doctors almost never mention it as a possible side effect. So I'm not trying to scare you away from it, just trying to let you know that it's a possibility.
* Rexulti: This is also approved for adjunct with an antidepressant for MDD. It is made by the same company as Abilify, and many try to call it "Abilify 2.0," and while it has similar mechanisms of action to Abilify, its binding profile is quite different and thus its effects are quite different. Rexulti can either be stimulating or sedating (usually somewhere in between... for me it was sedating so I took it at night). It may have a higher chance of causing weight gain than Abilify, but not much for most people (in fact, under the side effects, both weight gain and weight loss are listed). Many find Rexulti to be more tolerable than Abilify. It's newer than Abilify, and is brand-name only, but there is a copay coupon that lowers the copay to I think $5 if you go to the website for the medicine. Your doctor may have a sample starter pack that comes with a coupon as well. Typically you start 0.5 mg for a week, then 1 mg for a week, and then you can go to the target dose of 2 mg, but some people need to either go up slower or start lower (0.25 mg) and go up from there. Depending on your doctor's clinical experience with their patients on this medicine, they may actually give you two or three starter packs and may tell you to go slower than it says to and possibly even split the 0.5 mg tablets in half at first. Rexulti seems to be more "calming" than Abilify,
* Vraylar: This isn't actually indicated (yet) as an adjunct to an antidepressant for MDD, but it is indicated for the depressive phase of bipolar disorder. So it can be used off-label for this indication. For depression, the starting dose and target dose is 1.5 mg, but you can go up to a max of 3 mg/day (higher doses are usually reserved for bipolar mania and schizophrenia). Vraylar tends to be weight-neutral/metabolically friendly, possibly even more so than Abilify. The possibility for akathisia with Vraylar tends to actually be pretty high compared to Abilify even though they claim it should be less likely (based on its mechanism of action). For me, Vraylar was somewhere between Abilify and Rexulti when it comes to feeling "stimulated."
* Latuda: So far, the antipsychotics I've mentioned work on the dopamine receptors differently than most antipsychotics--they are "partial agonists" instead of "antagonists" (they modulate dopamine receptor activity based on the brain's baseline dopamine levels rather than just blocking the activity of dopamine at dopamine receptors). If your doctor decides to try you on any of the three above antipsychotics and you're unable to tolerate them because of how stimulating they are, the dopamine antagonists may be better for you. Latuda also isn't indicated as an adjunct to an antidepressant for MDD, but it is also indicated for bipolar depression. For most, the lower doses tend to be somewhat stimulating (some bipolar patients even have mania from low doses), and higher doses start to become more calming and even sedating. For me, the lowest dose of 20 mg is stimulating, at 40-60 mg I didn't really feel much of anything, and 80 mg actually knocked me out at first and even after I got used to it I was still pretty sedated. 120 mg is the max for bipolar, and 160 mg is the max for schizophrenia. For depression, I doubt you would ever need to go above 40-60 mg. 20 mg should be sufficient. I've heard a lot of people saying this med is really bad for causing akathisia, but personally I've never experienced it... It is probably the most weight-friendly antipsychotic... When I first started it the first time I took it, I actually lost weight on it (it was also the first antipsychotic I had ever taken).
* If weight gain is something you want to avoid, stay away from Zyprexa and Seroquel/Seroquel XR. If that's not an issue for you, then these would be excellent for anxiety (probably not so much motivation). They're pretty sedating (some may not tolerate them because of how sedating they are). Both Zyprexa and Seroquel XR (but not regular Seroquel) are indicated as an adjunct for treatment resistant depression. Zyprexa tends to pair very nicely with Prozac, and actually is recommended to use the two together for severe depression. Zyprexa is one of the worst offenders, though, for causing diabetes, so this would definitely not need to be a long-term medication.

Sorry for the overwhelming wall of text, I know that was A LOT to process... (I have a problem with getting caught up in the minor details a lot with meds...) I am by no means a professional, nor am I trying to tell you how to take your meds. I'm simply offering suggestions of what to discuss with your doctor based on what my psychiatrists and doctors have done for me in the past. Also, I included as much info about what to expect with these meds, because many doctors/psychiatrists don't inform their patients of what is truly important information (I guess because they get in a hurry). (I don't know your doctor/psychiatrist, they may be really good about communicating with you, but I still wanted to mention what to expect).

Best of luck finding the right option for you!

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Default Sep 21, 2021 at 07:50 AM
  #13
Thank you for all this info--it's wonderful!!
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