Re: Time for bupropion to reach maximum effectiveness » NKP

I forgot to mention that the dosage of lamotrigine should be titrated to 300 mg/day if 200 mg/day is insufficient. Lamotrigine does not exhibit an all-or-nothing dosage-response. 200 mg/day can produce a partial improvement, whereupon going up to 300 mg/day can produce a much more robust improvement. If so, you really should stay at that dosage indefinitely or until you decide to discontinue it. Even a partial response to lamotrigine argues for indefinite treatment in the background - as is the case with low-dosage lithium. Upon a dosage increase of lamotrigine, there might be a temporary re-emergence of cognitive side effects, including short-term memory impairments. They might resolve completely. However, I can't suggest a time range for this to occur. Twice-a-day dosing is best. Teva sells an extended release formulation of lamotrigine - Lamotrigine XR. I would still take it twice a day.

If you respond well to 300 mg/day of lamotrigine, please let me know who the manufacturer is.

> > How long does it take bupropion to reach its maximum effectiveness? At what stage should I assess whether it is having the desired effect or not?
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> Are you using bupropion as monotherapy? If so, have you ever seen someone achieve full remission that way?
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> For what it's worth, I haven't. Surely, some people do.
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> I wouldn't stop treatment with buproprion for four weeks at 300 mg/day if side effects are tolerable. Usually, side effects are not an issue. If there is a perceptible, but unequivocal improvememt at 4 weeks, treating for another 2 weeks is usually indicated. Some people need 450 mg/day, but this is infrequent.
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> I you feel that you are not responding at all after 4 weeks at 300mg, you can:
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> 1. Increase the dosage to 450 mg/day for no longer than 2 weeks.
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> 2. Add a SSRI. Zoloft has a good reputation as an adjunct to Wellbutrin.
> * I think it best to consider Wellbutrin to be the adjunct when combined with other medications.
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> 3. Add a SNRI: I would choose Effexor first if you know you can easily tolerate any side effects that emerge. I would not discontinue Effexor if you receive an improvement of any kind with it. 300 mg/day is the top end of the dosage range. Don't consider Effexor a failure until 300 mg/day is tested for two weeks once that dosage is arrived at. Some people need more, but that is only infrequently.
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> 4. Add low-dosage lithium. I am becoming an advocate of using low-dosage lithium (300-450 mg/day) almost routinely in treatment-resistant depression, especially if there is any family history of Bipolar Disorder or, Schizoaffective Disorder (Bipolar subtype), and catatonic schizophrenia - IN THE ABSENCE of mania or psychosis. Kidney and thyroid function are affected in a dosage-dependent manner. At 300 mg/day I have no side effects, my blood tests are normal after 10 years of exposure to lithium, and there are no psychiatric side effects - apathy or brain-fog, for examples. At 450 mg/day, I relapse, and actually feel moderately worse. Lithium has a biphasic dose-response curve. It does opposite things at low versus high dosages, both clinically and pharmacologically with respect to glutamate release. The association seems to reflect my clinical reaction to low versus high dosages of lithium. If other people react in a manner similar to me, the dosage-window might be very narrow, so one might respond robustly (for depression) to only one dosage in the 150-450 mg range.
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> 5. Add a secondary amine tricyclic - desipramine or nortriptyline. I prefer nortriptyline. It is much more of a "mood brightener" and anti-anhedonic than desipramine is. Also, desipramine feels harsher, perhaps because of its potent norepinephrine reuptake inhibition. Trimipramine would be interesting to try, Although it is a tertiary amine, it is unique and remarkable in its lack of monoamine reuptake inhibition (DA, NE, 5-HT). I don't know what effects it has on trace amines. As far as tricyclics are concerned, I think the order of efficacy would be: clomipramine, amitryptyline, and imipramine. All three are dirty drugs that carry with them a large anti-cholinergic load. It is best to avoid them.
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> 6. Add a stimulant to all of this stuff? I don't know that I have ever seen someone achieve full remission by simply adding methylphenidate or an amphetamine to an ongoing treatment regime. Perhaps you have.
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> 7. Add lamotrigine to all of the above.
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> 8. Discontinue Wellbutrin and forget about it if nothing above works, and no one has other suggestions on how to augment it.
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> There is a fine line when choosing treatments between selection based on logic and inference versus throwing as much crap against the wall and hope that something sticks.
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> Good luck.
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> - Scott
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Some see things as they are and ask why.
I dream of things that never were and ask why not.

The only thing necessary for the triumph of evil is that good men do nothing.

Re: Time for bupropion to reach maximum effectiveness » NKP

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