Upping to 450 mg Wellbutrin XL?

I'm currently taking Lexapro 40 mg along with 300 mg Wellbutrin XL for MDD and anxiety. I take the WB to augment the Lexapro, as well as to deal with some of Lexapro's side effects (mainly anorgasmia). When I first upped to 300 WB XL, I felt the difference in about a week. I felt normal, even good for about 4 days. The last couple of days I've felt iffy. It doesn't help that it's gone from being really cold and blindingly sunny (I love sun, don't care about the cold...I'm a bit SAD-ish in there i'm sure too) to being really grey and drizzly. Total yuck. I also have a couple of stressful things coming up later this week.

Pdoc (who I see again in 2 weeks) said that I should go up to 450 Wellbutrin after a week at 300 if I wasn't feeling better. Thing is, I *was*- for about 4 days. Every time he has suggested a med change, he ramps it up pretty quickly. I started seeing him when I was only on 20 mg Lexapro and it had stopped working. Right away, we upped it to 30, and then after (only) a week at 30, he said to up it to 40, for example. This seems fast to me, but maybe this is what they usually do. Dunno.

Anywho, one of the stressful events is coming up this weekend. I have to go out of town to visit my mother with my kids, it involves being in the car for 6 hours each way. Not exactly relaxing.

So, my question is: Do I up to 450 mg WB? (I know pdoc would want me to do this.) And if so, when? I am thinking it might be safest to wait until Monday, when I am back in town, if I this feeling doesn't pass by then.

Also, I'm really wondering if I simply haven't given 300 mg enough of a chance. I started 150 mg on Jan 20, then upped to 300 mg on Jan 28, which means I've been on 300 for about 12 days.

I'm not feeling unbearable. Just a bit down with some low-level anxiety.

I guess the nagging thing at the back of my head is the risk of seizure. I don't have any of the risk factors. I did ask pdoc about this, he said that 450 mg of the XL is fine- that other formulations at high dosages carry more of a risk.

Also wondering if it is okay to take the odd 0.5 mg of ativan when the anxiety is a bit too much. I don't take it regularly, and I've never taken more than 1 mg total in a day.

The other nagging thing at the back of my head is that maybe it's all about the Lexapro. It has worked at various doses- for awhile. Maybe it isn't quite right for me. The next step he said would be to swap the Lexapro for Cymbalta.

Help? Anyone?

BETosca, you have a lot of stuff going on with your different meds and in your life too. Because right now you report feeling only a bit down and low level anxiety, I think you should hold off on increasing Wellbutrin until after this weekend's stressful events are over. Wellbutrin is not given for anxiety and can increase it, so I think increasing it right now before the upcoming stressful events is not a good idea, especially since your current anxiety level is only low. After the weekend, revisit the idea of increasing Wellbutrin. THat's just my opinion....

I increased Wellbutrin several times (up to 300 at one point) and each time, I experienced a few days of really feeling great, then it declined somewhat as I got used to it and my body adapted. So don't be worried about the first few days feeling different than later--that's not unusual. I do think being on Wellbutrin 300 for 12 days is enough time to know if it is doing the job for you. You were on a lower dose so already had a lot in your system, and there is not as long a ramp up with Wellbutrin as with SSRI ADs.

Lexapro is given for depression and anxiety. Not all ADs help with anxiety, but this one often does. If you feel you have been increasing Lex and Wellbutrin too fast, tell your pdoc you want to do it more gradually. I can't imagine anyone with argue with slowing down the rate of increase, especially if your depression/anxiety symptoms are not severe.

Have you tried some phototherapy to help with the SAD?

You seem worried you increased Lexapro too rapidly. What is making you think that? Are you having bad side effects? I don't know whether your increase was too fast or not, but usually people have some sort of specific complaint(s) if their increase was too fast, and you didn't mention anything.

Do you have a prescription for ativan? I think your pdoc is the best one to answer your questions about whether you should add ativan to your Lexapro and Wellbutrin and what dose. If the increased Wellbutrin is contributing to higher anxiety, then adding another drug to combat that seems kinda crazy, if you know what I mean, but that's the way things go when we're on multiple drugs. One drug helps solve the problems of another, rather than helping with our underlying symptoms. Maybe just take less Wellbutrin and then less need for ativan. But maybe you think having more Wellbutrin is essential to deal with the anorgasmia. There are often trade-offs. It's complicated, yeah. That's why we pay those pdocs.

I have heard that the risk for seizure with Wellbutrin is negligible until you start getting above 300. You can read up on the seizure risk on the Internet and see what it is at 450--sounds like your pdoc feels it is still too low to worry about. Ask him to show you some numbers!

Ouch. Cymbalta can be very hard to come off, so proceed with caution, but it can help people for whom SSRIs fail. Are you really sure there is a problem with your Lexapro? What symptoms do you have that are not helped by your Lexapro? Depression symptoms? Anxiety symptoms? If it were me, and anxiety was too high and not controlled by Lexapro, I would rather add a benzo like ativan than change to Cymbalta. But that's just my opinion and personal preference.

You describe your current depression as "just a bit down." Maybe Lexapro is really helping then, and the last little bit you can work on with regular exercise, getting enough sleep (very important), phototherapy, and psychotherapy.

Here is something I often wonder and this is just me thinking out loud. Wellbutrin is often added to an SSRI to "augment" it and fix SSRI side effects like lethargy and anorgasmia. Wellbutrin is itself an AD. Why don't more docs start with Wellbutrin, which doesn't have those particular side effects? Why aren't more people on Wellbutrin alone? Maybe you would do OK on Wellbutrin only, and get rid of the Lexapro. That won't help your anxiety, but why not Wellbutrin + Benzo instead of Lexapro and bad side effects? I'm sure that's very naive thoughts on my part, but I have wondered. Because Wellbutrin alone helps quite a few people with their depression, in the absence of any SSRI.

Good luck to you and with your stressful events this weekend.

Thank you so much sunrise for your detailed response...you've given me a lot of food for thought.

I'm not feeling anxious, but I do feel depressed. Still, it's not as bad as it's been in the past. My motivation is zero. I can get the basics done at home, but not much more.

I have decided for sure to hold off on increasing the Wellbutrin until I get back from the weekend. I just don't think it's a good idea to do a med change while that far away from home. And it gives me a few more days to give 300 mg a fair shake. I would start the 450 mg on Tuesday, which means I will have been on the 300 mg for a total of 17 days.

I'm sorry I wasn't more clear- I never had any side effects with Lexapro, either starting it or when the dosages were increased. I guess I was just surprised that the pdoc said I'd notice positive changes in *a week*- and if not, to increase again. I guess a week sounded too good to be true. Thing is, he was right- after a week of all of my increases (this is true for both Lexapro and Wellbutrin) I felt better. The issue is for how long.

For example, when I first started Lexapro, it took about 3 1/2 weeks to kick in. I distinctly remember the first day I felt better, it was like a switch had flipped. That lasted for about 5 weeks, and then I started to feel the depression kick in again. We went up to 20 mg at that point- that took a week to kick in before I felt better, and then I felt well for about 2 weeks. This has been the pattern consistently, with both Lexapro and then Wellbutrin. When I added the Wellbutrin at 150, it took a week to kick in. Then I felt well for a week. And then it went downhill. And so it goes.

I do have a prescription for ativan. I don't take it often, and when I do, it's only half a mg at a time. He said it's fine to take as long as I don't take it too close to my trazodone (which I take for sleep). When the meds stop working, it's more depression than anxiety, so I don't usually take it.

And yes, Lex + WB seems to be the gold standard. My pdoc said that current studies (which he is involved in, as he's part of a major teaching hospital) show that these together work better than either alone for many people. I think WB is added to give more of a dopamine (and a bit of norepinephrine) boost, to also counteract some of the fatigue that can accompany many SSRIs.

I'm not too worried about coming off Cymbalta. I was on Effexor a few years ago, and I did a long, slow taper and had no problems at all coming off. I do remember however feeling like hell quickly when I'd occassionally miss a dose.

I'm intrigued by phototherapy. I think it wouldn't hurt, and I know many have reported success. I have been taking a vitamin D supplement as well, along with B6 to help with PMS-ish stuff. That's another thing- not sure if this is coincidence or not- but since I started on this merry go round, many of the times I went down hill it was during my PMS week. I'm sure it's all connected somehow. Doesn't help that my cycles are super short, like 21 days long. I also wonder if this is part of perimenopause (I'm 42).

Thanks so much for your support. I just gotta keep believing that things will get better.