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Nortriptyline trial a failure?

Posted by glennb on December 4, 2008, at 16:24:57

I have been in a trd/mdd episode for over a year. Was previously taking fluoxetine on and off for about 10 years with different augmentors never really reaching remission or eating into dysthymia but staying mostly functional. Over the years experimented with most of the other SSRIs, wellbutrin, lamictal (i think was somewhat helpful), depakote.

This year I started to spiral and spend full days in bed. I switched to a lengthy effexor trial which didn't go well, and also tried to augment effexor with mirtazapine. By this point I was in bed sleeping 16 or so hours most days for several months and doctors were recommending ECT.

I opted instead to try a TCA and have had a partial response to nortriptyline. It's been about 10 weeks and I basically have blocks of mediocre/good days followed by blocks of really, really bad days. I hit about 50/50 mediocre/good days to bad days 8 or so weeks in. I then slipped back and am now in bed for 10+ days and I'm hearing ECT and partial hospitalization again.

Next steps before the relapse was to augment with lithium; given the relapse, does it indicate the partial response to nortriptyline was placebic, noise, or just not significant enough to warrant trying to augment? in other words, should I drop the nortriptyline entirely and try another TCA (anafranil would probably be next) or just try lithium augmentation with fluoxetine, the only real anti-depressent I've had a response from.

I have no history of bipolar though am very irritable and sometimes have raciness and difficulty focusing which I attribute to the OCD. No mania or euphoria. I have comorbid ocd which is not bothering me as much as the depression. I have irritability which is controlled by SSRIs but is now pretty high; the nortriptyline doesn't seem to control it.

I currently also take 1mg klonopin nightly and 5-10mg ambien. Have had to bump up ambien to 20mg recently, which is very odd, been steady on 5-10 for probably close to 10 years.

I appreciate very much any thoughts.




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