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Re: thoughts on treatment of depression -cam

Posted by Kristi on May 22, 2001, at 0:52:33

In reply to Re: thoughts on treatment of depression (long) Paige, posted by Cam W. on May 21, 2001, at 14:03:41

Cam..... I have been learking around here for a while.. and find you also wonderfully knowledgeable and helpful.... agree with paige there. You said you were 10 weeks now? Can I ask what dose? Kristi

> Paige - Unfortunately, everyone's body chemistry is different and we still do not have very many reliable &/or consistent rules of thumb for choosing antidepressants for different people (unless their depression is vastly different - eg. atypical depression). Many disease states and many medications can induce or exacerbate depression, as can many lifestyles. A depressed person's temperment and lifestyle also play a role in an efficient doctor trying to decide what antidepressant (or combination of meds) are needed to most likely produce the best results, with a minimum of unwanted effects (ie side effects). Unfortunately, many doctors in the Western world do not (or cannot) take the time necessary to fully explore all these avenues (and other avenues that I am not thinking of, at the moment). I believe that following is more important than any medication in the treatment of depression.
> I believe that one of the best ways to overcome the above problem is to enter into a "therapeutic alliance" with your doc. This concept relies on a developing a "concordance" with your doc rather than just having you play a "compliance" role, with the doctor calling all the shots. Simply speaking, reaching a therapeutic alliance through concordance occurs when there is open, two-way dialogue between the depressed patient and the doc. Both sides (doc & pt) bring something to the alliance. The doc brings the clinical and scientific expertise, as well as personal prejudices. The patient brings their philosophies of medicine and disease states (in this case, depression) and personal prejudices. Both the patient and the doctor must find a happy medium, without bruising the egos of, or trivializing the philosophies of either party.
> This scenario changes the role of the doctor from an authority figure (do-as-I-say-compliance model) to that of an educator (let's-arrive-at-a-compromise model). The patient must be fully honest and forthcoming with the doctor, disclosing all pertinent information of their life and illness, as well as doing the leg work to learn about depression (this board is one information source). This allows the patient to become an "informed consumer" and if one knows why a med causes a side effect and/or therapeutic effect, they are more likely to stay on that med through the start-up side effects and be better able to wait out the lag time until therapeutic effect.
> The doctor needs to be able to assemble all pertinent information on depression and have the ability to 'shuffle' that information into a form that applies to that particular patient. The doctor then needs to be able simplify the information for the patient (tailored to their level of understanding). This informtion should include any pertinent treatment options, including those which are nonchemical (eg. psychotherapy, massage, etc.). The patient must provide feedback as to which treatment(s) best suits their philosophies and lifestyles. This feedback must be ongoing throughout therapy.
> So, in your case, the doctor should tell you why he/she wants to try Effexor XR (venlafaxine) and why and when he/she is considering the addition of Wellbutrin SR (bupropion) and the reasoning for these choices. Also, nonchemical (non-drug) options and/or adjuncts should also be offered, justified, and encouraged.
> Sorry, for the long-windedness of the above, but it sets up my answers to your questions.
> 1) Thoughts on augmentation of Effexor XR with Wellbutrin SR.
> This combination is used quite often, usually to avoid or reverse the longterm sexual side effects that can occur with Effexor XR. These two antidepressants have different mechanisms of action. At higher doses (approx. >225mg), Effexor XR morphs from an SSRI (like Paxil or Zoloft) to an SNRI (where both serotonin- and norepinephrine-reuptake is blocked). The mechanism of action of Wellbutrin SR (I truly believe) is unknown. The block of norepinephrine- and dopamine-reuptake does not occur unless one takes very high doses of the drug ( >450mg daily), and the maximum recommended dose is 300mg daily (to avoid seizure potential). We do know that Wellbutrin is effective in some depressions, so there may be some other unknown reaction (adenosine-A1A block?, second messenger changes? ) occuring.
> I would recommend a full trial of Effexor XR first. This includes slowly raising the dose up to approximately 300mg (or higher - 450mg to 600mg - in some cases of severely resistant depression). One should try a maximally tolerated dose of Effexor XR for a good 4 weeks before giving up on it. This means that one should take the Effexor XR at maximal dose for four weeks, thus an adequate trial of Effexor XR may be 10 to 12 weeks of treatment from the first dose (depending on the person's tolerability and the time it takes to reach maximal dose) before giving up on the drug.
> 2) Do I like Effexor XR?
> Quite frankly, I do not like taking any medication, but this one (so far) doesn't have the side effects of Paxil or Zoloft. At about 10.5 weeks on the drug, I have not gained any weight (actually lost some), but weight gain usually does not occur with an SSRI until one has taken it for 12 to 20 weeks. Also, rather than the loss of libido and delayed ejaculation that I experienced with the Paxil and Zoloft, I am much more hypersexual, with thigh-weakening, explosive orgasms, taking the Effexor. Again, it is too early to know if this little bonus will last.
> I am getting side effects with the Effexor XR, especially for a couple days upon each dosage increase. I find that I get 'fuzzy' thinking, insomnia, and diarrhea-constipation (believe it or not, at the same time). For me, these side effects do fade within a couple of increasing the dose and are not dibilitating. A constant thirst is the only side effect that has not gone away, but I have already become use to it. Anyway, I should be drinking more water.
> Everyone's body is different and what is good for me and the effects that I experience will be different from yours. As it says at the top of the page, YMMV (your mileage may vary). So, saying which antidepressant is better for you is impossible for me to say. The Wellbutrin has worked for me in 3 past depressive episodes, but did not touch this current one. This depressive episode is slightly different than the others, which were triggered mainly by job/life stress. This episode was triggered by the death of my 18 year old daughter last June 5, while on holiday at Disney World. So, I now consider this depressive episode to be slightly different than my previous ones (ie. this depression is either more severe or a slightly different breakdown of my HPA axis - part of the body's stress control mechanism - has occurred).
> 3) Effexor v. Effexor XR / Wellbutrin v. Wellbutrin SR
> Really, the XR (extended release) and SR (sustained release) are just the respective company's long-acting formulations. By ultimately extending the elimination half-life of a drug, one is able to take fewer doses of the drug per day, in a higher dosage. So, instead of taking Wellbutrin three times daily, you only need to take it twice daily for all day antidepressant activity.
> The XR form of Effexor is a more important improvement. The regular Effexor has a very short elimination half-life of 4 to 6 hours and thus Effexor needs to be taken twice to three times daily. Regular Effexor is notorious for causing withdrawl symptoms, because when the increased serotonin levels fall too much, the characeristic serotonin withdrawl symptoms (flu-like symptoms, headache, light headedness, etc.) emerge. The elimination half-life of Effexor XR is 11 to 15 hours, and thus the XR version can be taken once or twice daily without serotonin levels falling too much. Taking the Effexor XR once daily, I have found that I do wake up a little anxious and this anxiety goes away within the hour after I take the drug. The elimination half-life of Effexor (& XR) does increase slightly as you stabilize on the drug.
> 4) Would I take Effexor XR and Wellbutrin SR together?
> I guess, if I had to. Since Wellbutrin has worked for me in the past, if the Effexor XR were not to fully work (or stop working) I probably would consider adding Wellbutrin SR. This would be more an issue if I were extremely tired from the Effexor XR. As it was, I was only really tired on the Effexor XR for the first 6 weeks, so I think that the Effexor XR should be given a chance to resolve the tiredness on it's own.
> Sorry for the long post, but now that I am getting more energy all the time, I am getting rather long-winded. I hope that this is of some help to you. - Cam




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