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Dr. Bob is Robert Hsiung, MD,
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Posted by SLS on July 12, 2018, at 14:40:31
In reply to Re: Switching from Abililfy to Saphris. » SLS, posted by ed_uk2010 on July 12, 2018, at 13:12:41
> I wonder whether the dose-response relationship of Effexor is quite flat when on an NRI-type TCA such as nortriptyline?
>
> I was wondering whether you should avoid going above 225mg or so initially, just in case it's counter-productive. Maybe give it a few weeks before pushing too high?
>
> I think the anxiety will improve a lot over the next few days since it seems so clearly related to vortioxetine. Hope lorazepam is helping.I think you are right about the anxiety. My doctor agrees with you. I'm guessing that the Effexor has made it worse temporarily. There is a trill in my voice and my hands are shaky.
Thanks for your contributions here on Psycho-Babble.
- Scott
Posted by ed_uk2010 on July 14, 2018, at 7:18:55
In reply to Re: Switching from Abililfy to Saphris. » ed_uk2010, posted by SLS on July 12, 2018, at 14:40:31
>I'm guessing that the Effexor has made it worse temporarily. There is a trill in my voice and my hands are shaky.
I think that could easily happen if you increase Effexor too rapidly. I do think the anxiety would respond to lorazepam or diazepam though.
I do believe venlafaxine is a good antidepressant, although hardly first-line with the high incidence of withdrawal symtoms and initial nausea etc. Although higher dose are more effective for a subset, I must admit I'm unconvinced by the usefulness of ultra high doses vs licensed doses - especially since the approved maximum dose is already very high. Increasing beyond the approved dosage range often seems to cause more fatigue rather than more efficacy. I think it's probably more useful to wait longer (on 75mg/day in moderate depression and 150-225mg in severe depression), rather than ramping it up to 300-375mg too fast. I think people usually have fewer adverse effects and comparable response by doing this. Less initial agitation, nausea, tiredness etc.
Oh, and you may find this interesting. Perhaps it is why duloxetine isn't a very good antidepressant compared to venlafaxine!
https://www.ncbi.nlm.nih.gov/pubmed/26437230
Posted by SLS on July 14, 2018, at 11:54:42
In reply to Re: Switching from Abililfy to Saphris. » SLS, posted by ed_uk2010 on July 14, 2018, at 7:18:55
> >I'm guessing that the Effexor has made it worse temporarily. There is a trill in my voice and my hands are shaky.
>
> I think that could easily happen if you increase Effexor too rapidly. I do think the anxiety would respond to lorazepam or diazepam though.
>
> I do believe venlafaxine is a good antidepressant, although hardly first-line with the high incidence of withdrawal symtoms and initial nausea etc. Although higher dose are more effective for a subset, I must admit I'm unconvinced by the usefulness of ultra high doses vs licensed doses - especially since the approved maximum dose is already very high. Increasing beyond the approved dosage range often seems to cause more fatigue rather than more efficacy. I think it's probably more useful to wait longer (on 75mg/day in moderate depression and 150-225mg in severe depression), rather than ramping it up to 300-375mg too fast. I think people usually have fewer adverse effects and comparable response by doing this. Less initial agitation, nausea, tiredness etc.
>
> Oh, and you may find this interesting. Perhaps it is why duloxetine isn't a very good antidepressant compared to venlafaxine!
>
> https://www.ncbi.nlm.nih.gov/pubmed/26437230Interesting. Thanks, Ed.
- Scott
Posted by Robert_Burton_1621 on July 15, 2018, at 0:05:30
In reply to Re: Switching from Abililfy to Saphris., posted by SLS on July 14, 2018, at 11:54:42
> > >I'm guessing that the Effexor has made it worse temporarily. There is a trill in my voice and my hands are shaky.
> >
> > I think that could easily happen if you increase Effexor too rapidly. I do think the anxiety would respond to lorazepam or diazepam though.
> >
> > I do believe venlafaxine is a good antidepressant, although hardly first-line with the high incidence of withdrawal symtoms and initial nausea etc. Although higher dose are more effective for a subset, I must admit I'm unconvinced by the usefulness of ultra high doses vs licensed doses - especially since the approved maximum dose is already very high. Increasing beyond the approved dosage range often seems to cause more fatigue rather than more efficacy. I think it's probably more useful to wait longer (on 75mg/day in moderate depression and 150-225mg in severe depression), rather than ramping it up to 300-375mg too fast. I think people usually have fewer adverse effects and comparable response by doing this. Less initial agitation, nausea, tiredness etc.
> >
> > Oh, and you may find this interesting. Perhaps it is why duloxetine isn't a very good antidepressant compared to venlafaxine!
> >
> > https://www.ncbi.nlm.nih.gov/pubmed/26437230
>
> Interesting. Thanks, Ed.
>
>
> - ScottAs it happens, Scott, I can myself confirm the efficacy of Ed's suggestion. When on effexor some years ago, I found no extra benefit in increasing beyond 75mg - 150mg. My psychiatrist (not well-versed in psychopharmacology: when effexor pooped-out, he advised there were no further strategies for me! MAOIs far too dangerous, etc. etc.) advised, however, to keep pushing. I was on over 375mg and developed restless leg syndrome and agitation as a result. I had an excellent response to the lower doses for eight weeks(when the supposed NRI action had not kicked-in). But it pooped-out. This has been my experience with any SRI which worked: quite rapid improvement (very noticeable just a few days after first dose), but inevitable poop-out.
I suppose you'd already be familiar with the strategey of adding mirtazapine to effexor. I tried this without any benefit at all. M is pretty much just an extremely powerful H1 antagonist.
All the best. Sorry to hear the vortioxetine didn't agree with you (my experience was just the same).
R
Posted by SLS on July 15, 2018, at 8:20:48
In reply to Re: Switching from Abililfy to Saphris. » SLS, posted by Robert_Burton_1621 on July 15, 2018, at 0:05:30
Hi R_B
> As it happens, Scott, I can myself confirm the efficacy of Ed's suggestion. When on effexor some years ago, I found no extra benefit in increasing beyond 75mg - 150mg. My psychiatrist (not well-versed in psychopharmacology: when effexor pooped-out, he advised there were no further strategies for me! MAOIs far too dangerous, etc. etc.) advised, however, to keep pushing. I was on over 375mg and developed restless leg syndrome and agitation as a result. I had an excellent response to the lower doses for eight weeks(when the supposed NRI action had not kicked-in). But it pooped-out. This has been my experience with any SRI which worked: quite rapid improvement (very noticeable just a few days after first dose), but inevitable poop-out.
>
> I suppose you'd already be familiar with the strategey of adding mirtazapine to effexor. I tried this without any benefit at all. M is pretty much just an extremely powerful H1 antagonist.
>
> All the best. Sorry to hear the vortioxetine didn't agree with you (my experience was just the same).
Thanks for your input. I will try remaining between 75-150 mg/day of Effexor. I began to experience what I can only guess is a form of serotonin syndrome when going up to 150 mg/day after only two days at 75 mg/day. That was silly of me. I became mentally altered. I felt dissociated and detached from my environment. Lots of bruxism. I skipped my dose of Effexor today. I take it in the morning.
- Scott
Posted by Lamdage22 on July 15, 2018, at 23:55:42
In reply to Re: Switching from Abililfy to Saphris. » Robert_Burton_1621, posted by SLS on July 15, 2018, at 8:20:48
Effexor seems to make more sense in the way that you may not need an antipsychotic with it to protect you from mania/psychosis like you would with Parnate. That will help your weight and metabolism.
Have you taken Effexor before?
Posted by ed_uk2010 on July 18, 2018, at 13:59:56
In reply to Re: Switching from Abililfy to Saphris. » Robert_Burton_1621, posted by SLS on July 15, 2018, at 8:20:48
Hi Scott,
How are you doing? Were you able to restart venlafaxine OK?
Posted by SLS on July 18, 2018, at 14:24:59
In reply to Re: Switching from Abililfy to Saphris. » SLS, posted by ed_uk2010 on July 18, 2018, at 13:59:56
> Hi Scott,
>
> How are you doing? Were you able to restart venlafaxine OK?I'm an idiot. I had 150 mg capsules to work with. On day 1, I took 75 mg using one capsule and dumping out half of its contents. On day 2, I began to take 150 mg/day. I was okay for a few days, but began to feel strange and detached. I didn't expect this. I also experienced bruxism. Perhaps it was a hyperserotonergic state. I skipped two days. I felt very weird and began to deteriorate. Lots of anxietey. I felt like I was hit over the head with a baseball bat and was left dazed and confused. I took a small amount of Effexor, and my head began to clear. What a mess. My poor brain. I will see my doctor tomorrow.
- Scott
Posted by ed_uk2010 on July 21, 2018, at 15:38:01
In reply to Re: Switching from Abililfy to Saphris. » ed_uk2010, posted by SLS on July 18, 2018, at 14:24:59
Hi Scott,
Have you been able to tolerate a small amount of Effexor now?
Posted by SLS on July 21, 2018, at 16:34:56
In reply to Re: Switching from Abililfy to Saphris. » SLS, posted by ed_uk2010 on July 21, 2018, at 15:38:01
Hi, Ed.
> Have you been able to tolerate a small amount of Effexor now?
No. I skipped dosing yesterday morning. My head cleared by evening. The more severe depression reappeared this morning. I took a small amount of Effexor earlier. I had to open a 150 mg capsule and estimate. I am guessing that I took 30-40 mg. The depression lessened, but that weird zombie state emerged again. My head is beginning to clear now. I don't know what to think. I am concerned.
- Scott
Posted by ed_uk2010 on July 22, 2018, at 5:22:46
In reply to Re: Switching from Abililfy to Saphris. » ed_uk2010, posted by SLS on July 21, 2018, at 16:34:56
Hi,
How long is it since you stopped Parnate? And how long since vortioxetine? It sounds like you're extremely sensitive to Effexor due to the residual effects of other medication taken recently. Also, using the 150mg XR capsules is creating rather haphazard dosages with a prolonged effect, which might not be ideal during this time of hypersensitivity.
How about asking your psych for some plain/non XR venlafaxine 37.5mg tablets? The effects should wear off rapidly if there is a problem. You could take half a tablet (approx 18.75mg) in the morning for a while, and then increase to half a tablet twice a day as tolerated. If things are OK you could then return to Effexor XR. Do you think your doctor would go for that?
On the bright side, being hypersensitive to venlafaxine at least means it is doing something.
Posted by Lamdage22 on July 22, 2018, at 9:03:28
In reply to Re: Switching from Abililfy to Saphris. » SLS, posted by ed_uk2010 on July 22, 2018, at 5:22:46
I hope you can maneuver your way out of this.
Posted by Lamdage22 on July 22, 2018, at 9:10:38
In reply to Re: Switching from Abililfy to Saphris., posted by Lamdage22 on July 22, 2018, at 9:03:28
I dont remember a time when you were the one receiving advice like this down in a hole. At least you can communicate with people with your computer and you seem to have come past the suicidal urges.
Have you grown more skeptical of drugs in these bad times? What was the problem to begin with? Is it the same old thing now?
Posted by SLS on July 22, 2018, at 11:53:30
In reply to Re: Switching from Abililfy to Saphris., posted by Lamdage22 on July 22, 2018, at 9:10:38
> I dont remember a time when you were the one receiving advice like this down in a hole. At least you can communicate with people with your computer and you seem to have come past the suicidal urges.
Yes. The time immediately after discontinuing Parnate was dark and painful. I came off of it too quickly. Perhaps this left me overly sensitive to SRI drugs. I tapered Parnate in only ten days. I think I would have been better off using a taper period of a month or more.
> Have you grown more skeptical of drugs in these bad times?
That's a good question. I am not skeptical of the utility of antidepressant drugs in general. However, I am becoming less optimistic about my case specifically.
> What was the problem to begin with? Is it the same old thing now?
Parnate was a dead-end for me. It gave me more mental energy, but that's about it. In actuality, it suppressed motivation. I was in less pain, but also less apt to begin or finish activities.
Same old thing? Pretty much. Right now, my depression is less severe than it was years ago. Perhaps the other drugs I take are preventing me from relapsing completely. It is also possible that I will feel worse as time passes without taking Parnate.
Currently:
Nortriptyline 100 mg/day
Lamictal 300 mg/day
Lithium 300 mg/day
Prazosin 30 mg/day
- Scott
Posted by SLS on July 22, 2018, at 12:16:15
In reply to Re: Switching from Abililfy to Saphris. » SLS, posted by ed_uk2010 on July 22, 2018, at 5:22:46
> Hi,
>
> How long is it since you stopped Parnate?Almost 7 weeks.
> And how long since vortioxetine?
Almost 3 weeks.
> It sounds like you're extremely sensitive to Effexor due to the residual effects of other medication taken recently.
I imagine so.
> On the bright side, being hypersensitive to venlafaxine at least means it is doing something.It seems that even a small amount of Effexor produces an altered cognitive state. It makes me feel weird and detached. It is scary that this should happen. My head began to clear by the end of yesterday. I decided to discontinue Effexor and skipped my morning dose today. I'm doing okay so far.
- Scott
Posted by ed_uk2010 on July 22, 2018, at 12:25:00
In reply to Re: Switching from Abililfy to Saphris. » ed_uk2010, posted by SLS on July 22, 2018, at 12:16:15
You going to try for a bit just with your current combination then? Perhaps you could restart Effexor in a few weeks.
Posted by Lamdage22 on July 22, 2018, at 13:14:54
In reply to Re: Switching from Abililfy to Saphris. » ed_uk2010, posted by SLS on July 22, 2018, at 12:16:15
Well you will certainly find out if and what helps you.
Posted by SLS on July 22, 2018, at 13:18:23
In reply to Re: Switching from Abililfy to Saphris. » SLS, posted by ed_uk2010 on July 22, 2018, at 12:25:00
> You going to try for a bit just with your current combination then? Perhaps you could restart Effexor in a few weeks.
I don't know what the plan will be. I will be seeing my doctor tomorrow. I would not be averse to revisiting vortioxetine first. I brought this up with him on the phone. The last time that I was on Effexor, I tolerated 300 mg/day easily. I was also taking nortriptyline at the time, but at a lower dosage.
- Scott
Posted by SLS on July 23, 2018, at 17:25:02
In reply to Re: Switching from Abililfy to Saphris. » ed_uk2010, posted by SLS on July 22, 2018, at 13:18:23
> > You going to try for a bit just with your current combination then? Perhaps you could restart Effexor in a few weeks.
>
> I don't know what the plan will be. I will be seeing my doctor tomorrow. I would not be averse to revisiting vortioxetine first. I brought this up with him on the phone. The last time that I was on Effexor, I tolerated 300 mg/day easily. I was also taking nortriptyline at the time, but at a lower dosage.I saw the doctor today and we discussed my recent difficulties with Trintellix and Effexor. He said that he has seen people's reactions to a drug vary at different times in their treatment history. We came to the conclusion that it makes sense to revisit Trintellix using low dosages. I have been tapering Effexor these last few days. Some withdrawal symptoms emerged, but are fading.
I am going through a difficult time emotionally. I am finding it necessary to reframe my life given my age, finances, employability, and health status.
- Scott
Posted by ed_uk2010 on July 24, 2018, at 9:15:41
In reply to Re: Switching from Abililfy to Saphris., posted by SLS on July 23, 2018, at 17:25:02
Hi Scott,
I must admit I'm a bit surprised. I did think you would feel quite averse to taking vortioxetine again. Does your doctor have a theory about how a lower dose may help now? You will stay on 5mg/day perhaps?
I have my own mini theory if vortioxetine doesn't work out this time. I was thinking you could stay off all additional serotonergic drugs (like vortioxetine) for around three weeks before trying Effexor again - a full 'wash out' if you like. I was thinking the unusual response to Effexor may have been related to the residual effects of medications taken during the few weeks before you started Effexor. Next time, you could start Effexor at 37.5mg/day perhaps. Just a thought.
Posted by SLS on July 24, 2018, at 9:29:51
In reply to Re: Switching from Abililfy to Saphris. » SLS, posted by ed_uk2010 on July 24, 2018, at 9:15:41
Hi, Ed.
> I must admit I'm a bit surprised. I did think you would feel quite averse to taking vortioxetine again. Does your doctor have a theory about how a lower dose may help now? You will stay on 5mg/day perhaps?
>
> I have my own mini theory if vortioxetine doesn't work out this time. I was thinking you could stay off all additional serotonergic drugs (like vortioxetine) for around three weeks before trying Effexor again - a full 'wash out' if you like. I was thinking the unusual response to Effexor may have been related to the residual effects of medications taken during the few weeks before you started Effexor. Next time, you could start Effexor at 37.5mg/day perhaps. Just a thought.I agree with you about my being sensitive to SRI drugs. I beat up my brain by discontinuing Parnate too rapidly and going on and off vortioxetine and Effexor. I was tempted to wait a few weeks before restarting a SRI, but I am impatient to get relief. I began taking vortioxetine at 2.5 mg/day. The plan is for me to stay there for a week and then increase the dosage to 5.0 mg/day. I don't know what to expect. I can only hope.
I appreciate and value your help.
- Scott
Posted by Lamdage22 on July 24, 2018, at 9:55:16
In reply to Re: Switching from Abililfy to Saphris., posted by SLS on July 24, 2018, at 9:29:51
Hmm. I think you will find the combo that works best for you. I am in the situation you were in when you were still taking Parnate+Abilify.
Posted by SLS on July 24, 2018, at 11:39:32
In reply to Re: Switching from Abililfy to Saphris., posted by Lamdage22 on July 24, 2018, at 9:55:16
Hi, Lamdage.
> Hmm. I think you will find the combo that works best for you. I am in the situation you were in when you were still taking Parnate+Abilify.
How so? Do you feel stuck?
- Scott
Posted by Lamdage22 on July 24, 2018, at 11:43:23
In reply to Re: Switching from Abililfy to Saphris. » Lamdage22, posted by SLS on July 24, 2018, at 11:39:32
At times i do. But not constantly
Posted by ed_uk2010 on July 25, 2018, at 4:27:00
In reply to Re: Switching from Abililfy to Saphris., posted by SLS on July 24, 2018, at 9:29:51
Hi Scott,
Do you feel anything from vortioxetine 2.5mg? I suppose it's difficult to say what is causing what right now.
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