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Dr. Bob is Robert Hsiung, MD,
bob@dr-bob.orgShown: posts 1 to 25 of 40. This is the beginning of the thread.
Posted by Dispossessed on February 27, 2014, at 15:38:13
Hello,
Its my first time posting here - I have, however, read quite a few posts and it seems that people here really know their stuff.
Anyway, I was wondering what could have caused me to experience a sudden hypersensitivity to SSRIs and their side effects?
Keeping it as short as possible - I was on 20mg of fluoxetine between 2003 and 2011 for 'pure O' OCD and mild depression, which generally worked at minimising anxiety/depression. Even though it wasn't a good idea, I drank alcohol whilst taking it. Anyway, I noticed around mid 2011 that I was starting to feel a bit more restless (now I think it was a glutamate rebound from drinking alcohol the previous evening) and suspected the medication was to blame, given its reputation for being activating. Briefly tried switching to citalopram, 10mg, then 20mg after a week, but experienced a worsening of intrusive thoughts/akathisia and so stopped. I was on citalopram for around 10 days in total.
After a couple of days I felt great no restlessness, no intrusive thoughts. I went for 3 months like this before experiencing worsening depression/anhedonia (I was drinking moderately each day). I tried reinstating 20mg fluoxetine, making a considerable effort to avoid alcohol/caffeine, but experienced horrible akathisia, sexual side effects, restlessness, agitation some of these side effects were new/greatly worsened this time around.
Long story short, since then, I have been unable to tolerate SSRIs at a standard therapeutic dose. I found that fluoxetine was far too activating, sertraline (25mg) caused blurred vision and severe cognitive problems (I took this for 4.5 weeks and none of these side effects went away), fluvoxamine at 50mg gave me akathisia, restless legs and a general sense of dread.
I did however find that just 5mg of citalopram gave me great relief from my anxiety/intrusive thoughts, and had a moderate impact upon depression. At this dose I could tolerate caffeine again and felt nicely calm. However, it caused visual side effects and cognitive dysfunction even though I gave it 5 months, these side effects didnt lessen. I believe that these side effects relate to its antihistamine properties I switched to fluvoxamine afterwards, which, as mentioned above, didnt help me with the physical anxiety I face (though it had minimal impact upon cognition) and when I augmented with quetiapine I experienced the familiar cognitive dysfunction/blurred vision that I did with citalopram, albeit to a greater extent.
What I am therefore asking is why am I so sensitive to the anticholinergic and antihistaminic properties of these drugs, and why does any serotonergic medication at even a low dose cause me akathisia/restlessness? I gave sertraline a month if I was to try it again (or even paroxetine) would the anticholinergic side effects like blurred vision and cognitive dysfunction fade over time, and if so, how long should I wait?
I can tolerate a low dose SSRI (5mg of fluoxetine helped with depression) but need something more to manage the physical anxiety/OCD. Any (non-benzo) suggestions? I have a hypersensitive nervous system, suffer OCD intrusive thoughts, general sense of anhedonia, poor concentration, fear of change/unfamiliar situations, and physical restlessness. I suspect some of these issues may relate to alcohol use (even though it was never heavy) and so have stopped drinking completely. I have also had blood tests to rule out any physical causes.
Many thanks for reading.
Posted by phidippus on February 28, 2014, at 18:23:54
In reply to Sudden sensitivity to SSRIs/side effects?, posted by Dispossessed on February 27, 2014, at 15:38:13
Describe your akathisia.
There are many alternatives to SSRIs when it comes to treating OCD. Here's a list:
Keppra
Riluzole
Lyrica
Gabapentin
Zonegran
Memantine
Ondansetron
Pindolol
Buspar
ClomipramineHave you tried treating the akathisia?
Eric
Lithium 1200 mg
Brintellix 20 mg
Invega 6 mg
Vyvanse 70 mg
Posted by Dispossessed on February 28, 2014, at 20:51:44
In reply to Re: Sudden sensitivity to SSRIs/side effects? » Dispossessed, posted by phidippus on February 28, 2014, at 18:23:54
Thanks for the reply.
The akathisia is a feeling of mild panic/unease coupled with an overwhelming desire to move my legs and arms (I can sit still if I really want to though). Like a kind of agitation. I'm also clenching my jaw a lot. The thing is - I never used to have this agitation/restlessness when taking SSRI medication, it was only after discontinuing fluoxetine, living med-free for a few months, and reinstating it.
I tried propranolol at various doses but it didn't seem to help that much, and I got some bad stomach pains from taking it. I understand that anticholinergics can help, but I am sensitive to anticholinergic side effects. I tried sertraline and clomipramine and experienced blurred vision that made it impossible to drive, and severe cognitive dysfunction.
Thanks for the suggestions. I was definitely going to ask about pregabalin (Lyrica) as its licensed for GAD in the EU and seems to be very good for anxiety, though tolerance seems to build rapidly. The only real issue is the effects it will have on cognition. After all, I experienced memory loss and cognitive dysfunction on 5mg of citalopram and 25mg sertraline - which are meant to have minimal cognitive side effects, particularly at such low doses.
Posted by merpmerp on March 1, 2014, at 8:47:36
In reply to Sudden sensitivity to SSRIs/side effects?, posted by Dispossessed on February 27, 2014, at 15:38:13
Hi Dispossessed,
I don't have an answer for you exactly, but I wanted to know you're not alone.
I took 20-30 mg Prozac for about a year back in 2006-2007, and it was literally a lifesaver. I was taking it for severe melancholic depression, and I don't drink alcohol ever, for additional info.
Thought I was "fixed", went off it. Didn't take anything for a couple of years.
Went back to Prozac in early 2009, it made me much worse. Even at 10 mg. Intrusive violent thoughts, severe akathisia (I didn't know what that was back then), panic attacks, shakiness. I switched to the name brand thinking it was a bad generic, no relief.
Now I'll try to recall exactly what happened and in what order, but my memories of the following are pretty hazy.
Switched to 10 mg Lexapro. At first it seemed better. Then I couldn't concentrate and started sleeping like 15 hours a day. Then, I can't remember why, I think my psych upped it to 20 mg, maybe in anticipation of the winter months. BAM, severe intrusive thoughts, akathisia, panic attacks for which she gave me Klonopin. Like you, I had blood tests, thyroid tests, therapy, before suspecting my med. Went back to 10 mg, was still bad. Went to 5 mg, still bad. Went to 2.5 mg, perfect. Felt great. That was early 2011 and I was really good for a few years. I still take it.
So why am I back here on Psychobabble then? Well, all of a sudden, I am having the akathisia, panickiness (I describe it as feeled constantly "revved up" physically, and nothing will calm me) and other symptoms. Much milder than before, but I want to cut it off at the knees before it gets going.
I think my main problems may be dopamine related. So I think serotonin isn't really my issue, and too much of it exacerbates the dopamine problem.
Why I suddenly got sensitive to the 2.5 mg Lexapro... I'm not sure. Except that as we age, I'm sure our brain chemistry changes and sadly what worked once may not work again. Perhaps my suspected dopamine problem is worsening. I've been through some stressors and may be responding to that; maybe it'll even itself out, maybe it won't.
As to your question about how long you should give an SSRI to work, I always figure around a month, but on the other hand, with Lexapro, I always felt the dose changes within three days, like clockwork.
Now I may have missed this, but have you tried Wellbutrin? I have not, and that may be next for me.
Best of luck to both of us.
Posted by bleauberry on March 1, 2014, at 12:16:02
In reply to Sudden sensitivity to SSRIs/side effects?, posted by Dispossessed on February 27, 2014, at 15:38:13
Lyme disease should be considered. To keep a long story short, your post has some clues in it, but the most striking clue is right in the title. imo Hey, I see what I see. Been there done that. The story you wrote, sounded like mine.
You won't find blood testing helpful, so please do not rely too much on those. They help round out the big picture, but that is all. For example, a negative lyme test does not mean one does not have lyme. A thyroid test in the normal range does not mean that thyroid is operating properly for that person. This is all clinical stuff, not lab stuff. Detective stuff, not academic stuff. Gray stuff, not black and white. Your symptoms are solid gray, nothing black and white in there at all.
If your docs think they ruled out physical causes, I would like to respectfully disagree. The tests needed to accomplish that would be financially prohibitive. Instead we have to narrow them down to what makes sense for the symptoms. For example, you have plenty of symptoms in your post to warrant a Western Blot from Igenex Labs for a Lyme panel with Bartonella and Babesia added on. In my experience, it is Bartonella that causes more psychiatric stuff than the other bugs do. My sensitivities and depression and akathisia and all that crap pretty much melted away on antibiotics.
Anyway, I just wanted to share a perspective maybe you hadn't been exposed to. It is worth thinking about. Only 1 in 10 infected people is diagnosed. 9 go undiagnosed or misdiagnosed.
My Lyme doc last week said he sees a lot of psychiatric patients in his practice and that for the most part that all pretty much resolves with antibiotics. He and another MD I used to see are of the opinion that most psychiatric patients are actually infected.
I think you would do well to start putting together a list of Integrative MDs, or Lyme MDs, or any MDs with a good reputation for creative thinking and customized treatments, so you can get evaluated. Whatever your psychiatric diagnosis is, represents only a piece of the bigger picture. Without even asking, I would guess you have other symptoms that you didn't mention, since they seem unrelated and non psychiatric. Well, they are related.
Sensitivity is an immune system thing. Something screwed it up. What do you think might do that? Infection? Toxins? Metals? All of the above? Any or all.
My 20 years of depression was actually Lyme disease the whole time. It was finally correctly diagnosed at about the time the meds were failing me as you so accurately described in your post. They don't just fail....they fail in a certain way, a certain pattern, not random, it has a look to it. And you described it very well.
Posted by merpmerp on March 1, 2014, at 12:37:35
In reply to Re: Sudden sensitivity to SSRIs/side effects?, posted by bleauberry on March 1, 2014, at 12:16:02
Dear Bleauberry,
Was that directed more at me or more at Dispossessed? Either way, it is definitely worth thinking about. I believe I have indeed come across the odd article about someone who displayed psychiatric symptoms who was finally after many years diagnosed with Lyme.
Posted by Dispossessed on March 1, 2014, at 21:29:16
In reply to Re: Sudden sensitivity to SSRIs/side effects?, posted by merpmerp on March 1, 2014, at 8:47:36
Thanks for the replies.
Merp - I certainly think that dopamine has something to do with my reaction to SSRIs - my lack of libido, poor attention, as well as the restlessness/akathisia appear to suggest this. I haven't tried bupropion - and I don't think the chances of being able to are great to be honest, as its not licensed in the UK for depression (only smoking cessation). I'm considering asking my GP for another referral to a psychiatrist, who may be likely to suggest it off-label. Did you ever try citalopram? It is more sedating than escitalopram (Lexapro) because it has higher affinity for histamine receptors - it may help with the restlessness perhaps.
Bleauberry - thanks for your post - Lyme disease is something that I've considered, and its possible as well. I've been hillwalking in areas where infected ticks potentially live. I'll mention it to my GP next time, but to be honest, he probably thinks that all my issues are psychiatric in nature. As its the NHS doctors prefer not to send people for blood tests because of the cost - and I'm not in a situation to afford to pay for private tests at the moment :(
Posted by g_g_g_unit on March 1, 2014, at 22:26:39
In reply to Re: Sudden sensitivity to SSRIs/side effects?, posted by merpmerp on March 1, 2014, at 8:47:36
I'm in the same position as you guys, merpmerp and Dispossessed. It's pretty frustrating.
I know Moclobemide is quite popular in the UK. There's an account of it treating tardive akathisia, so that might be an option, Dispossessed.
Posted by SLS on March 1, 2014, at 22:51:40
In reply to Sudden sensitivity to SSRIs/side effects?, posted by Dispossessed on February 27, 2014, at 15:38:13
How about trying Latuda (lurasidone)?
It is a weight-neutral, antipsychotic with antidepressant properties that takes advantage of serotonin 5-HT7 receptor blockade without reuptake inhibition. It is also a 5-HT1a partial agonist and a 5-HT2a antagonist. All of these things might come together to produce a clean antidepressant/anxiolytic response with just enough D2 antagonism to prevent hyperactivity in the prefrontal cortex (PFC).
http://www.ncbi.nlm.nih.gov/pubmed/20404009
- Scott
Posted by Dispossessed on March 2, 2014, at 9:22:02
In reply to Re: Sudden sensitivity to SSRIs/side effects? » Dispossessed, posted by SLS on March 1, 2014, at 22:51:40
I know that the akathisia will go away if I lower the dose or stop taking the medication, but then the intrusive thoughts/depression/anxiety come to take its place. I guess I could return to 5mg citalopram, which helped the anxiety/OCD without giving me akathisia, but at the cost of cognitive/visual problems. So its a double-edged sword.
Scott - thanks for the suggestion. It does seem that lurasidone lacks the cognitive side effects of the other APs, but it doesn't have approval in the UK yet. I'm also unsure as to what D2 receptor antagonism would do in terms of the akathisia/restlessness I get from the SSRIs - would it not worsen it?
Posted by SLS on March 2, 2014, at 10:05:08
In reply to Re: Sudden sensitivity to SSRIs/side effects?, posted by Dispossessed on March 2, 2014, at 9:22:02
> Scott - thanks for the suggestion. It does seem that lurasidone lacks the cognitive side effects of the other APs, but it doesn't have approval in the UK yet. I'm also unsure as to what D2 receptor antagonism would do in terms of the akathisia/restlessness I get from the SSRIs - would it not worsen it?
Akathisia is the result of D2 receptor blockade in the striatum. Latuda avoids this area. I hope this drug is made available to you soon. Stay away from SRIs (SSRIs + SNRIs) if you can. What non-SRI antidepressants have you tried? Have you tried Remeron (mirtazapine)? What about Solian (amisulpride)?
- Scott
Posted by Dispossessed on March 2, 2014, at 17:18:53
In reply to Re: Sudden sensitivity to SSRIs/side effects? » Dispossessed, posted by SLS on March 2, 2014, at 10:05:08
I've not tried mirtazapine - medication with antihistamine properties helps with anxiety/restlessness, at the cost of visual disturbances and cognitive dysfunction. I was on citalopram for 5 months and the visual/cognitive issues didn't fade at all. I've also tried low dose quetiapine, which had quite a sedating effect. I was told that the sedation would wear off eventually - but after just a day of taking it I was experiencing the same visual/cognitive issues that I experienced on citalopram.
Tell me more about amisulpride? I've heard of some people using it in low doses for depression.
Posted by phidippus on March 2, 2014, at 18:22:26
In reply to Re: Sudden sensitivity to SSRIs/side effects? » Dispossessed, posted by SLS on March 1, 2014, at 22:51:40
The problem with suggesting an antipsychotic without the benefit of an AD is worsening of OCD symptoms.
Eric
Posted by Dispossessed on March 2, 2014, at 18:40:06
In reply to Re: Sudden sensitivity to SSRIs/side effects? » SLS, posted by phidippus on March 2, 2014, at 18:22:26
Yes, I've heard that too. I can tolerate small doses of SSRIs - its just that at higher doses, I feel considerably more restless.
What kind of effects would antipsychotics have upon cognition in non-psychotic individuals out of interest? What about sexual function, motivation and concentration also (which I also have issues with?)
Posted by phidippus on March 2, 2014, at 19:03:54
In reply to Re: Sudden sensitivity to SSRIs/side effects?, posted by Dispossessed on February 28, 2014, at 20:51:44
> The akathisia is a feeling of mild panic/unease
coupled with an overwhelming desire to move my legs and armsThese could be just panic symptoms. When I have panic attacks I get the same kind of motor agitation.
The problem for you is SSRIs and Clomipramine are the most widely studied medications used to treat OCD. It is widely acknowledged that OCD is a result of a depletion of serotonin in key areas of the brain. It is also believed that excess dopamine is also involved in the pathonogenises of OCD-especially an excess of dopamine in the nucleus accumbens, which is the target of novel therapies for OCD namely deep brain stimulation. Other theories for the root cause of OCD involve glutamatergic models which have been studied-Topomax and Riluze, both anti-glutamatergic, have shown promise in the treatment of OCD, but these medications are always used alongside an SSRI.
If you want to treat your OCD appropriately, you need to take an SSRI to fix the serotonin imbalance in your brain. If you don't get enough response, you add a low dose AP. Then you add an anti-glutamatergic.
You need to find a way to treat the akathisia so you can take an AD or you're going to get nowhere.Eric
Posted by Dispossessed on March 2, 2014, at 19:11:42
In reply to Re: Sudden sensitivity to SSRIs/side effects? » Dispossessed, posted by phidippus on March 2, 2014, at 19:03:54
Thanks for your reply.
What would you recommend?
Once I get the feeling of panic under control I'm going to also consider CBT again. If CBT is the most successful way to treat OCD, does this mean that it is possible to rectify the serotonin imbalance without medication?
Posted by phidippus on March 2, 2014, at 19:13:05
In reply to Re: Sudden sensitivity to SSRIs/side effects?, posted by Dispossessed on March 2, 2014, at 18:40:06
You don't want to do an AP without an AD when treating OCD.
As for the cognitive effects of APs, it just depends on the AP. Latuda supposedly enhances cognition in schizophrenics.
APs have never effected my sexual function. Some have affected my motivation and some have effected my concentration.
Eric
Posted by merpmerp on March 2, 2014, at 19:27:42
In reply to Re: Sudden sensitivity to SSRIs/side effects?, posted by Dispossessed on March 1, 2014, at 21:29:16
I have tried citalopram, but only for like a couple of months. It was prescribed for a transitional period in my life. Since I was on it for such a short time, I can't remember how it was really. It might have helped a little.
I've been continuing to worsen, and have cut my 2.5 mg Lexapro to 1.25 mg daily. If I improve under this, I will contact my doctor and say I want off the Lex. The frequent diarrhea, intrusive violent thoughts, extreme muscle tension, crying spells are all back just like they were 4 years ago - and at that time, lowering the dosage was what fixed it. We will see.
Posted by phidippus on March 2, 2014, at 19:46:55
In reply to Re: Sudden sensitivity to SSRIs/side effects?, posted by Dispossessed on March 2, 2014, at 19:11:42
> What would you recommend?
I would recommend getting back on an SSRI and aggressively treating the akathisia. Beta-blockers are front line medication for akathisia, but a bunch of other medications have been shown effective:
Benzodiazapines
Opiates
Amantadine
Requip
Mirapex
Clonidine
Guanfacineand remember, OCD requires high doses of SSRIs to be treated adequately - Zoloft up to 400 mg, Prozac up to 60 mg, Lexapro 50 mg, etc.
>If CBT is the most successful way to treat OCD, does this mean that it is possible to rectify the serotonin imbalance without medication?
CBT is not the most succesful way to treat to treat OCD, though it can be helpful, along with DBT. The most successful teatment for OCD is ERP (exposure and ritual prevention). Its best to find a therapist who speciacalizes in OCD and ERP along with CBT therapies. ACT is very helpful as well.
Therapy will not rectify serotonin imbalances, but will provide you the tools to cope with OCD. ERP will affect brain circuits directly, lessening the brains response to perceived danger.
Eric
Posted by phidippus on March 2, 2014, at 19:50:11
In reply to Re: Sudden sensitivity to SSRIs/side effects?, posted by merpmerp on March 2, 2014, at 19:27:42
That's hardly a therapeutic dose. Most studies show OCD responds to high doses of SSRI treatment. What's the highest dose you have been on?
Eric
Posted by Dispossessed on March 2, 2014, at 20:06:25
In reply to Re: Sudden sensitivity to SSRIs/side effects? » Dispossessed, posted by phidippus on March 2, 2014, at 19:46:55
Thanks for that Eric - will try and arrange an appointment with a psychiatrist and throw a few suggestions his way.
I've tried propranolol at various dosages but have always found the side effects a bit hard to take (GI pain, epic gas) with no noticeable benefits. I was always told that it works well as a prn, but would I need to take it for a few days for it to have a noticeable effect on the akathisia? I know I should have given it a proper trial, but the GI issues are not particularly nice, particularly if spending a lot of time with close friends/loved ones!
I'm still on an SSRI (fluvoxamine) but still only at a low dose - 50mg. I'd like to increase but I know that the restlessness/jaw clenching are side effects of the drug and would only worsen.
You mentioned whether the akathisia was in fact anxiety symptoms - is there any way to tell whether it is that rather that akathisia? The SSRIs help reduce the intrusive thoughts and general anxiety I have, but make me feel more restless inside - when I'm in bed or at the computer I have to move my legs a lot or else I feel uncomfortable.
Posted by SLS on March 2, 2014, at 20:24:37
In reply to Re: Sudden sensitivity to SSRIs/side effects? » SLS, posted by phidippus on March 2, 2014, at 18:22:26
> The problem with suggesting an antipsychotic without the benefit of an AD is worsening of OCD symptoms.
I defer to your knowledge in this area.
Thanks.
- Scott
Posted by phidippus on March 3, 2014, at 14:56:46
In reply to Re: Sudden sensitivity to SSRIs/side effects?, posted by Dispossessed on March 2, 2014, at 20:06:25
> I've tried propranolol at various dosages
What dosages?
>would I need to take it for a few days for it to have a noticeable effect on the akathisia?
No, the effects should be readily apparent. In other words, you should have experienced rapid relief.
>I know I should have given it a proper trial,
but the GI issues are not particularly nice
perhaps another beta blocker would work instead. propanalol doesn't work for me either, but I've found pindolol helpful-espcially helpful for OCD as it is a 5ht1a agonist.> I'd like to increase but I know that the restlessness/jaw clenching are side effects of the drug and would only worsen.
That isn't necessarily true. Akathisia sometimes levels off at certain dosages.
> You mentioned whether the akathisia was in fact anxiety symptoms - is there any way to tell whether it is that rather that akathisia?
Taking a dose of benzodiazapine may unmask the anxiety.
> The SSRIs help reduce the intrusive thoughts
Remember, its not what the intrusive thoughts do to you, rather what you do with the intrusive thoughts.
you have no symptoms of restlessness when you're off the SSRI, correct?
The other thing you can try is a different antidepressant, one you haven't been on. I really like Viibryd and Brintellix.
Eric
Posted by Dispossessed on March 3, 2014, at 19:37:08
In reply to Re: Sudden sensitivity to SSRIs/side effects? » Dispossessed, posted by phidippus on March 3, 2014, at 14:56:46
> What dosages?
I've tried propranolol at 10, 20, 40mg instant, and 80mg extended release. Do you think that the lack of response could be evidence of physical anxiety symptoms?
> Taking a dose of benzodiazapine may unmask the anxiety.
I have around 5 2mg diazepam tablets I could take. Being in the UK, doctors are reluctant to give out benzodiazepines even for occasional use. When I had a spell of increased anxiety/intrusive thoughts I asked the GP for some and received a total of 14 2mg tablets. 4mg doesn't do anything to be honest, but that's the NHS. They're paranoid about benzo addiction after what happened in the 80s. I could take 10mg but I want to keep them in case I have a really, really bad day.
> you have no symptoms of restlessness when you're off the SSRI, correct?
I don't have the physical restlessness when off SSRIs, no. Certainly no restless legs/jaw clenching.
> The other thing you can try is a different antidepressant, one you haven't been on. I really like Viibryd and Brintellix.
I don't have that many options regarding antidepressants left. I could return to citalopram and be anxiety free but experience cognitive/visual issues. I haven't tried paroxetine but I'm unsure how long it would take for the anticholinergic side effects to fade. There was no change in visual/cognitive issues when I took sertraline, and I discontinued because it was seriously affecting my ability to study. Unfortunately the two drugs you mentioned are not available in the UK - the latter has been approved but will be released in the second half of 2014 (estimated).
> Remember, its not what the intrusive thoughts do to you, rather what you do with the intrusive thoughts.
I know what you mean. Though when I feel panicky and fear about losing control, the fear of acting on them is very real. I do have a book on OCD which told me to make a recording of the worst case scenario and play it back to myself on a loop - I made the recording but never listened to it on a daily basis because when the thoughts are particularly intrusive, its very easy to become demoralised.
Posted by SLS on March 3, 2014, at 20:31:02
In reply to Re: Sudden sensitivity to SSRIs/side effects?, posted by Dispossessed on March 3, 2014, at 19:37:08
I'm sorry to interrupt and ask a question that may have already been addressed, but how does your OCD manifest? Is it obsessions and ruminations only, or is there a compulsive counterpart including rituals?
I don't know. I am still looking at Latuda if you are ruminating and not experiencing compulsions. I have not researched this possibility well enough to recommend it, though. I would try the Brintellix first.
How did you respond to Luvox and clomipramine?
Perhaps Phiddipus can comment on combining Brintellix and nortriptyline. You would be adding NRI + 5-HT2a antagonism. Both drugs are metabolized by the same enzyme (CYP450 2D6), though. You might have to reduce the dosage of nortriptyline. With nortriptyline, you can get blood tests to use as a guideline for dosing. Adding the nortriptyline might help with depression, ruminations, and the anxiety that accompanies depression (as opposed to an anxiety disorder).
- Scott
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