Dr. Bob's Psychopharmacology Tips

Other antidepressant mixtures

Date: Fri, 8 Dec 1995 21:28:03 -0500
From: gsdavids@niagara.com (George Davidson)
Subject: Mixing fluoxetine and venlafaxine

A number of my patients, independent free-thinkers that they are, have tried augmentation -- using leftovers from one prescription -- with amazing effects. This is having me rethink things considerably. I have two patients now who have discovered (a) a non-response with Prozac or (b) a response with side effects with high dose Effexor can turn into (c) a good response without side effects on Prozac *and* Effexor.

Date: Sat, 11 May 1996 05:35:34 -0500
From: gsdavids@niagara.com (George Davidson)
Subject: Mixing SSRIs

Some of my patients have been mixing SSRIs on their own initiative, quite succesfully, and I have to approve of the results. A couple of well known, respected psychiatrists have suggested it to me when I have asked for advice.

I don't see why it would be such a bad thing to do -- my worry is that there seems to be no way to know when you are in danger of the serotonin syndrome until it happens.

I have seen combinations of SSRIs (and venlafaxine [Effexor] and nefazodone [Serzone]) used to get the advantages of both with less of the side effects of each. I have also seen combinations where the side effect of one is used to balance the side effect of another.

The most ingenious combination I've seen so far is 60 mg per day of Prozac with 75 mg per day of Effexor -- she does this because the Effexor works better than the Prozac for her, but to get the full antidepressant effect she would need a much larger dose of Effexor, which would cost a lot more because it is not on her drug plan.

Date: Sat, 22 Aug 1998 15:16:16 -0400
From: Ivan Goldberg <Psydoc@psycom.net>
Subject: Mixing bupropion, nefazodone, and mirtazapine

I get to see a large number of patients with "resistant" depressions. In the course of treating such patients I have used all possible combinations of bupropion, nefazodone, and mirtazapine, including the triple combination on a few occasions. It has been my impression that such combinations are usually well-tolerated and, every now and then, spectacularly successful. But usually they are not all that much better than the agents used singly.

Date: Sun, 27 Sep 1998 23:33:51 -0500
From: Larry Ereshefsky <ereshefsky@uthscsa.edu>
Subject: Mixing mirtazapine and venlafaxine

Stephen Stahl, whom I regard as the guru of the psychopharmacology of depression, advocates such combinations as Remeron (mirtazapine) and Effexor (venlafaxine) for difficult to treat depressions and made no mention of any particular risk of serotonin syndrome during a recent workshop I attended.

--Jim Glover, M.D.

The combination of mirtazapine and venlafaxine is very powerful. I view it as "big gun" therapy, almost equal to ECT. There is a risk of serotonin syndrome, as there is with many augmentation strategies which affect the same system at several levels. It all comes down to benefit vs. risk.

Date: Thu, 1 Oct 1998 18:24:46 -0500
From: Larry Ereshefsky <ereshefsky@uthscsa.edu>
Subject: Mixing mirtazapine and venlafaxine

Anecdotally, this combination is being used with good success. Granted, it's not controlled for time on drug, etc, but treatment resistant patients are not likely to undergo spontaneous remission or placebo response.

Folks like Norm Sussman, Alan Schatzberg, and others I have served on program panels with suggest they have had good success in selected patients.

Whether the combination works better than either alone is not answerable with data. However, the neurochemical effects of these drugs are non-duplicative, and the end result should be greater outflow of NE and 5HT.

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