When SSRIs and SNRIs are no longer affective, what are my other options?

Uh, I can only think of one...and on that note, can I have your stuff?

Electro Convulsive Therapy.

^^Or ketamine

R1 lol, thanks for not disappointing when it came to being the first reply

Booze, sweetie darling.

ECT or TMS treatment

Have you tried St. John's Wort? It worked for me for two years, and then I got on a pharmaceutical. But now they're taking my one antidepressant off the market, and I'm thinking of tapering off both of mine and going back on it. Just make sure you get a trusted brand.

This

Talk therapy, ECT, ketamine, deep brain stimulation, diet and exercise

Adderall

this, doll

Lamotrigine or other mood stabilizers.

A Fisher-Wallace Stimulator. The Fisher Wallace Stimulator is a neurostimulation device that is alleged to improve your depression, anxiety, and insomnia by stimulating your brain to produce serotonin with a gentle electrical current. It’s FDA approved.

Check out microdosing mushrooms. People say that it works better than antidepressants. Ketamine therapy has also helped a lot of people, but it’s expensive. I looked into it last year and they wanted $2k just for the initial treatments.

[quote]Ketamine therapy has also helped a lot of people, but it’s expensive. I looked into it last year and they wanted $2k just for the initial treatments.

That's ridiculous they charge so much. Ketamine is a very old drug that is used in anesthesia and it's very cheap.

Meditation and prayer

Jesus

Journaling

You need to reach out, hunny. Have some contacts, supports, friends to bounce things off of.

I see a doctor of psychology once a week and he’s cute

R14 also ketamine can trigger schizophrenia in some

micro-dosing shrooms sounds fun

Oprah reruns.

OP, the only thing left for you is ECT. Lots of drool and short term memory loss. Unfortunately for us, you won't be on here as much. Darn.

light box therapy. It’s not pseudo science, it’s been studied and is shown to help people depressed if there is a seasonal component to it.

Besides SSRI and SNRI, there are old drugs like tricyclics and MAOs. They’re older and full of side effects but also pretty effective.

Have you tried Trintellix? It’s sort of novel, it’s a serotonin modulator. How about Wellbutrin? it’s an NRI

High kicks while wearing caftan and high stiletto boots. Long blonde wig.

Prozac has always been the gold standard for treating my depression and anxiety.

But like many others, it stops working for me after about 2 years - it's often called the Prozac Poop-out.

When the Prozac stops working for me, I change to another SSRI, usually Celexa or Lexapro.

Neither Celexa or Lexapro works as well as Prozac, but they work well enough with talk therapy and my other support and coping therapies.

After about 24 months, I go back to Prozac and it works likes the first time again - the depression lifts like a fog.

It's a cycle I've been using for 20 years to manage my depression. It's not perfect but surviving and getting older is often a process of learning to manage conditions for which there is no magic cure.

Finding alternatives for Prozac was a matter of trial and error. Celexa and Lexapro are both good for me - not as good as Prozac, but much better than the alternatives.

As I've gotten older and more experienced, I've becoming better at recognizing and managing the symptoms of the depressions, sort of separating/protecting myself from the thoughts and feelings of the depression.

I keep hoping for another breakthrough drug like Prozac - and I've tried a lot of them - so far, Prozac is the gold standard for me.

Prozac was derived from an antihistamine. Most depression has to do with histamines and the mast cell system. Mast cell is something that we’re just starting to learn about.

OP: I had a nice, long, beautiful (the most beautiful you've ever seen, many are saying) reply typed out and then my fucking browser crashed. Gone. Fuck it all to hell right in the asshole without lube! Let's see if I can remember the majority of it... Wellbutrin/bupropion hydrochloride (or bupropion hydrobromide/Aplenzin) is an NDRI: Norepinephrine-Dopamine Reuptake Inhibitor used for depression. Of note, the other drugs classified as NDRIs are the psychostimulants used for the tx* of ADHD, narcolepsy & short-term tx of obesity (as appetite suppressants), e.g., dexmethylphenidate, amphetamine, dextroamphetamine, methylphenidate, methamphetamine, and lisdexamfetamine; however, these meds are not used for depression; bupropion is the only NDRI used for Major Depressive Disorder and Seasonal Affective Disorder. (*Note: "tx" is the medical abbreviation for the word "treatment.")

There is a new treatment called Spravato, which is a non-competitive N-Methyl-D-Aspartate Receptor Antagonist, and is the more active & potent left-handed S(+) enantiomer/isomer of ketamine, called esketamine. It is, like ketamine, an analogue of phenylcyclohexyl piperidine, usually shortened to phencyclidine, and more commonly known as PCP/angel dust. As such, its prescription is tightly controlled & monitored via an REMS (Risk Evaluation & Mitigation Strategy) program, because it is a federally Schedule III Controlled Substance. It must be administered with direct supervision by the prescriber in a certified inpatient or outpatient treatment clinic. And like ketamine, it's a very promising new tx for tx-resistant MDD and MDD patients who are acutely suicidal.

Another option are the Serotonin Modulators: old-school trazodone & nefazodone, and the newer vortioxetine (Trintellix/Brintellix) and vilazodone (Viibryd). Alternatively, the TCAs & TeCAs (tricyclic & tetracyclic antidepressants), like: doxepin, amitriptyline, imipramine, amoxapine, notriptyline, clomipramine, mirtazapine, desipramine, protriptyline, maprotiline, trimipramine, etc. They are all used for the tx of depression; a couple are also used for anxiety (namely, doxepin & imipramine).

Of course, we can't forget the Monoamine Oxidase Inhibitors (MAOIs), like phenelzine, selegiline, isocarboxazid & tranylcypromine. However, MAOIs can cause very nasty adverse reactions/side effects and their use is contraindicated in combination with many other commonly prescribed medications. If at all possible, avoid them.

If we were talking Bipolar I Disorder with acute depressive episodes, lurasidone/Latuda and cariprazine/Vraylar, which are both 2nd-generation antipsychotics, would be two options. Similarly, aripiprazole/Abilify, olanzapine/Zyprexa and quetiapine/Seroquel are used as adjunct-tx for MDD, specifically tx-resistant MDD. By drug class, all three are also 2nd-generation antipsychotics.

That's all I got. In other words, there are numerous different treatment options beyond SSRIs & SNRIs for depression/Major Depressive Disorder. Good luck, I hope you find a medication, or alternative treatment, that works for you & provides relief.

OP, there's Serzone (an MAOI) and Wellbutrin (not sure of its classification). Word of warning: I had a negative reaction to Serzone, almost allergic. Wellbutrin worked moderately for me, but also a "litany" (my doctor described it as such) of side effects, including vivid nightmares & stopped hair growth.

Other than rx drugs: cognitive behavioral therapy & just plain talk therapy (to someone caring & kind).

Good luck, OP.

The basic thing is life moves too fast now and no one appreciates or respects anything or anyone. Everything is disposable. There is a macro issue causing the outbreak of mental illnesses. We worship narcissists and have created an environment where they thrive.

[quote]no longer affective

Oh, dear.

Someone I know is trying ketamine, seems to be helping.

Plus he can dance all night now. Kidding.

Geezer r26 It sounds like some Haldol might be the thing for you.

Study Stoicism - or Buddhism. Or Existentialism? Though it seems like the same thing as Stoicism to me.

What are your issues, OP? Do you have trouble sleeping, do you eat your feelings, do you have a lot of fatigue or pain or anxiety? No way to know what drugs will be of help if you don't list all your problems. Personally, I find marijuana edibles are helpful.

R29 & R30: I've been taking "Serzone" (nefazodone) and Wellbutrin for 20+ years and as a combo, they've been working great. But! Teva has stopped making nefazodone, and I too am looking for something else to switch to before I run out of it in January. It works well for me because in addition to having depression, I was a chronic insomniac, and nefazodone worked to allow me to sleep 7-8 hours a night. BTW, I've tried trazodone, and it gave me horrible nightmares.

I've never taken other pharmaceuticals for depression. Any suggestions? TIA.

R37, outside of Serzone & Wellbutrin, there are:

1. Prozac.

2. Zoloft.

Those are the two that are different (active ingredient) from each other and from Serzone & Wellbutrin.

I was unable to tolerate both Prozac and Zoloft. Both take a few days or even weeks to start working.

R13 do you own one yourself? It sounds a little too good to be true to me.

Cognitive-behavioral therapy

Has anyone tried buspar (also known as buspirone)? My doctor has prescribed it for anxiety but I've heard it can help with depression as well.

[quote]Wellbutrin worked moderately for me, but also a "litany" (my doctor described it as such) of side effects, including vivid nightmares & stopped hair growth.

I'm on Wellbutrin. I find that I think a lot less on it so I worry a lot less.

Initial Issues: Anger, Far too much Energy, Itching (not quite the worst ... but still terrible), the worst for me was feeling like there were phantom hands touching my feet but only at night. My doctor had some fancy term for it that deals with psych.

All of that went away eventually, as my doctor predicted. The only real side effect now is that I sweat like you would not believe during the summer. (Apparently it happens in 1 in 5 people.)

Best Part: My friends all see me as a nicer, kinder person and they HATE IT.

Have you considered speaking to a medical professional, rather than ask a bunch of random people on a porn gossip site?

R43 you've never dealt with many shrinks, have you? They're the most full of shit of them all.

Acid or mushrooms. Ectasy.

R37: If it's mainly the antidepressant properties of the nefazodone which are beneficial to you, I would talk to your provider about perhaps trying vortioxetine/Trintellix or vilazodone/Viibryd in combination with the bupropion, since they are both newer Serotonin Modulators like nefazodone & trazodone. However, they aren't sedating like nefazodone & trazodone, so if you still struggle with insomnia, you may have to add another medication to treat it, like hydroxyzine (Vistaril, an old sedating 1st generation antihistamine) or doxepin (a sedating tricyclic antidepressant also used for insomnia; and since it's an antidepressant, you may want to just try the doxepin in combination with the bupropion and leave out the Trintellix or Viibryd and see how that combination works for you, if your provider agrees, of course).

Some use quetiapine/Seroquel as an adjunct tx for depression; it's an atypical antipsychotic by classification, and is also sedating, so it's prescribed for insomnia. I'm not a fan of using it as a first-line (or even second) tx option for insomnia. Often the adverse reactions outweigh the benefits. However, it is beneficial for some patients, so it could be an option to discuss with your provider.

Beyond that, there are, of course, the controlled substances (mostly C-IV) used to treat insomnia, but have addiction potential: benzodiazepines (like lorazepam/Ativan, temazepam/Restoril, diazepam/Valium, etc.), the Z-drugs (zaleplon/Sonata, eszopiclone/Lunesta, zolpidem/Ambien), and the orexin receptor antagonist suvorexant/Belsomra (also a C-IV drug). There is one that isn't a controlled substance, it's the newer melatonin receptor agonist tasimelteon/Hetlioz.

Again, if I were you, I think I'd discuss with my provider the possibility of combining the bupropion with doxepin, since it's both an antidepressant (tricyclic) and it's sedating, in place of the nefazodone. Otherwise, like I mentioned, I'd ask about adding Trintellix or Viibryd and another medication for your insomnia. Good luck to you, I hope you can find a replacement for the nefazodone which offers you the same type & level of relief it has provided.

OP Dignitas, Switzerland.

Micro dosing mushrooms. Ketamine. There are many promising therapies now. Look into it.

OP, you should head over to the "I bought mushroom spores on Etsy" thread. Super helpful, and a few very knowledgable experts over there chiming in about microdosing mushrooms.

I have a friend who went to rehab for alcohol and was prescribed the following on discharge

Klonopin during the day

Before bed:

Seroquel Trazodone Topomax

I have taken all of these in the past except for the klonopin. Today, I only take trazodone every now and then when I can’t get to sleep.

But the combo above concerns me. Does it seem like a bit much?

Klonopin and Trazodone absolutely shouldn’t be combined. An anesthesiologist once told me if he wanted to go it would be his preferred combo.

R50: without knowing his diagnoses and medical history, just on its face with three different sedating medications, it definitely seems excessive. The topiramate/Topamax is expected; it's a useful and common med for alcohol use disorder. I'm not sure of the wisdom of using clonazepam/Klonopin, a controlled substance with addiction potential, in someone who has a history of alcohol addiction. That said, with clinical justification, I could probably get behind the use of the clonazepam and topiramate, but to then add quetiapine & trazodone on top of it...yeah, no, that seems excessive and potentially dangerous.

Which medications are best for severe anxiety?

Topomax also helps with weight loss as it acts on a receptor that controls appetite

Prayer, meditation,and meth.

I also went to rehab for alcohol. 5 years clean as of this past June. I did not like the topiramate and was changed to acamprosate which I attribute much of my sobriety to. I found that topiramate (or topomax) had earned the nickname dopomax as it made it difficult for me to remember things and find my words. Both of which were bad things in my profession.

Thanks for the heads up. Should I just pass this on to my friend, or make a bigger stink about it? I lean towards the former because like the above poster, I don't know all the details or the dosages for that matter.

^^ R50

Thanks so much R29/R46. I worry about it because I've been stable on this combination for so long, and I go to the VA for my health care, so my shrink (who is about to retire) is uninformed about current meds and truly doesn't give a damn. I can only hope that she'll be kind enough to give me a script for whatever I uncover in my research and doesn't give me a hard time about it. OTOH, I just switched to a new PCP (also through the VA, but way more attentive), so maybe she can prescribe it if the shrink balks. Again, thanks so much for the info, and I'll check it out right away.

R53: Your question is sort of vague in that you don't specify if you mean "the best" (which, of course, is highly subjective and will vary wildly from patient to patient) anxiolytic to treat/arrest an acute, active anxiety/panic attack or if you're asking about a daily medication used as a prophylactic to (hopefully) prevent anxiety spikes/attacks in the first place.

If the former, the gold standard treatment for acute anxiety/panic attacks--similar to how opiates/opioids are the gold standard analgesic treatment for acute, moderate to severe pain--are the benzodiazepines (BZDs). These include short-acting BZDs like alprazolam/Xanax & triazolam/Halcion; intermediate-acting BZDs like lorazepam/Ativan & temazepam/Restoril; and long-acting BZDs like clonazepam/Klonopin, diazepam/Valium & chlordiazepoxide/Librium, etc. It should be noted, even though all benzos have the same mechanism of action and work on the same receptor system, not all of them are FDA approved for the treatment of anxiety (e.g., Halcion & Restoril are approved for short-term insomnia tx, but not specifically for anxiety; however, they could still, potentially, be prescribed off-label for that purpose). That said, as previously mentioned, benzodiazepines, while very effective, are Schedule IV controlled substances with low-moderate abuse/psychological & physical addiction potential and should only be used for short-term PRN (as needed) tx of acute anxiety, not as daily medications.

If you're looking for a daily, prophylactic anxiolytic to (again, hopefully) prevent anxiety in the first place, the list is quite long. There are also several different classes of medications that can be used, including the two this thread is about: SSRIs like citalopram/Celexa, escitalopram/Lexapro, fluoxetine/Prozac, sertraline/Zoloft, fluvoxamine/Luvox, paroxetine/Paxil, etc. & SNRIs like duloxetine/Cymbalta/Drizalma Sprinkle, venlafaxine/Effexor/Effexor XR, desvenlafaxine/Pristiq and levomilnacipran/Fetzima; the tricyclic antidepressants doxepin/Silenor & imipramine/Tofranil; hydroxyzine/Vistaril/prev. Atarax (a 1st generation sedating antihistamine); prochlorperazine maleate/Compazine (a phenothiazine 1st-gen. antipsychotic most commonly prescribed as an antiemetic/antinausea med; trifluoperazine/Stelazine is another med of the same class also used for anxiety); buspirone/BuSpar (a serotonin 5-HT1A receptor agonist & dopamine D2 receptor antagonist); meprobamate/the former Miltown & Equanil (a carbamate similar to barbiturates which binds to GABA-A receptors and is an adenosine reuptake inhibitor, also C-IV similar to benzos), etc. And the list goes on... There are many, potentially effective, anxiolytics from which to choose. Finding the correct medication for you often requires trial & error until you find the one which works for you, and causes no, or minimal, but tolerable, adverse reactions/side effects.

R50/R56: I would recommend expressing your concern(s) to your friend and the reasoning behind that/those concern(s), and letting him/her make an informed decision with his/her, I hope, board-certified psychiatrist [M.D./D.O.] with a subspecialty certification in Addiction Medicine from the American Board of Psychiatry & Neurology; or, at least, a board certified Adult/Across the Lifespan P.M.H.N.P. (Psychiatric-Mental Health Nurse Practitioner) from the American Nurses Credentialing Center. If s/he isn't being treated, and prescribed that cocktail of medications, by a psychiatrist or psych NP, therein may lie the problem. I, myself, am a family medicine NP, and I do commonly prescribe psychotropic medications for patients who can't/don't/won't see a psych clinician, but again, at face value, I can't think of any reason I would prescribe that combination of medications for "just" an alcoholic; I cannot say other primary care providers (family medicine & internal medicine M.D./D.O.s, P.A.-C.s [Physician Assistant-Certified], F.N.P-C.{or -B.C.}s, A.G.P.C.N.P.-B.C.s [Adult-Gerontology Primary Care Nurse Practitioner-Board Certified], particularly if they're new & inexperienced, would be as cautious prescribing such a cocktail.

To further expand on my post at R52, I'm assuming your friend has several psychiatric comorbidities, but even so, I don't know why that fact would require treatment with quetiapine, trazodone AND clonazepam, all quite sedating and all used, off-label, for their anxiolytic effects. The topiramate, as I said in my previous post, is expected for a recovering alcoholic. The VA/DoD considers it, along with acamprosate, disulfiram & naltrexone, to be first-line treatment options for moderate-severe alcohol use disorder (AUD). Trazodone has been studied, and found somewhat helpful, for alcohol withdrawal (but since your friend is out of rehab, s/he should not be in acute withdrawal). Quetiapine, likewise, has been studied for use in treating alcohol dependence (mainly the mood/anxiety/insomnia component) and while it was found helpful, to my knowledge--though I could be wrong--it's not currently recommended as a 1st line tx in AUD patients. And lastly, clonazepam, is, of course, a very effective sedative/hypnotic & anxiolytic. It's also helpful for the secondary restless leg syndrome that can accompany alcohol & opioid withdrawal and can be used for acute alcohol withdrawal syndrome to prevent withdrawal-induced seizures, which can be potentially deadly, and to prevent/treat delirium tremens (DTs). Any BZD can potentially be used for alcohol withdrawal, but the two most commonly used and recommended are chlordiazepoxide/Librium and diazepam/Valium, along with clorazepate/Tranxene T-Tab and oxazepam/Serax. In fact, all four include acute alcohol withdrawal as FDA approved indications. Any other BZD used for that purpose would be off-label.

If your friend would relapse--and let's be honest, relapse is a normal, if not practically expected, part of recovery--while taking topiramate, quetiapine, trazodone and clonazepam, there is, in fact, a not-so-small chance, largely dependent upon dosages and the type & quantity of alcohol consumed, s/he could die to due profound CNS depression leading to respiratory depression and, perhaps, respiratory arrest and death. I can't even tell you the number of patients who go to the E.D. every year due to combining alcohol with their Klonopin or other BZD, never mind adding three other CNS depressants on top of it. All that said, and as previously noted, we don't know exact the diagnoses, the doses nor their dosing parameters & schedules, so it's difficult to definitively say (though it seems I pretty much have above, lol) it's excessive and unnecessary, but yeah, prima facie, it probably is. And with all of that in mind, absolutely, I would definitely express your concerns to your friend.

And last, but not least, R58: You're quite welcome. I wish you much luck & success in finding (a) new medication(s) that provide(s) relief for you. I'm disappointed to hear your psychiatrist is seemingly apathetic, or at least quite indifferent. She really should retire if she's done giving a damn about her patients. All the medications I mentioned are nowhere near new or novel; she should be well-versed in their indications, pharmacokinetics, pharmacodynamics, utilization, dosing regimens, etc. Even the "newer" Serotonin Modulators vortioxetine/Trintellix and vilazodone/Viibryd were developed almost a decade ago and have been FDA approved for the tx of MDD since 2013 & 2011, respectively. There's zero reason she should be uninformed on their use. Again, I'm not even a psychiatric NP, just a family NP, and obviously I know them well, as should every licensed clinician. Even if you're a gastroenterologist or dermatologist, I can't imagine you wouldn't, at least, know what they are and their general use indications. Anyway, your PCP definitely *can* prescribe it, so if your psychiatrist shirks her duty to her patient, hopefully your PCP will be okay with picking up the slack, as you suggested. Psychiatry and psychotropic meds are an art as much as a science and as mentioned in my previous post, it often requires some, or a lot of, trial & error--and patience--until you find the right medication, or combination of medications, for you and your diagnosis/es. Good luck and thank you for your service (medical care at the VA, I have to assume you're a veteran, so thanks!).

Apologies-ish for two long-ass posts in a row, followed by a third not overly long one, to anyone not interested in what I have to say. It's sort of my signature style.

Thank you for all the information R59 I feel like I've been on so many drugs over the years that I've lost count and none had helped(or helped enough) I suffer from severe Social Anxiety Disorder, Agoraphobia, and OCD as well as severe Depression so I need all the help I can get but living in a small town the more experimental treatments like such as magic mushrooms, LSD, or even marijuana aren't available to me.

This lady did a Ted talk on anxiety, just in case it helps...

Cognitive behavior therapy can be really good - if you have the money, there might be an online therapist who could help you. Or one of those self-help books. People laugh, but for me, it helps to make a plan, write it all down, and carry it out. Just the writing it down (journaling) is helpful.

Anyone tried imipramine? My doctor recommends it, but I can't find much about it online.

I missed FNP, welcome back.

[QUOTE] Anyone tried imipramine? My doctor recommends it, but I can't find much about it online.

Messy. Dry mouth, weight gain, orthostatic hypotension, drowsiness, and dizziness at effective doses for depression. Less so for the lower doses given for chronic pain and other non-psych ailments. Short life though, so if you take it daily don’t you dare skip a dose, you’ll feel like shit within 24 hours with a mild headache and malaise that gets worse until you dose again.

Yikes, R66! Even with the awful side effects, did it do anything to help with the depression?

oh yes, it sure did. I was pretty down with depression and also had panic attacks, this helped me a lot! Mind you, this was 1992 and I was on a limited budget as a ‘self pay’ patient so that was all I could afford in college.

OP here. I decided to check out the thread about growing your own shrooms and although I'm definitely interested, at the same time I'm discouraged by the fact that it sounds extremely difficult/complicated (for example, the jars and substrate the shrooms are grown in must be absolutely sterile or else the whole thing is ruined) and also growing and possessing is super illegal in my state, even without any intent to sell or distribute.

I'm desperate enough to give it a try though. I don't have much to lose.

Stop with all of that shit and take an SNRI that makes sense. PRISTIQ. I take 200mg upon rising in the morning and 200 mg at noon. I feel great.

OP, R69, if you look carefully through that thread, there's a recommendation for a place to buy capsules. Several posters on that thread have utilized it with no problems.

Crocheting new patterns can be both calming and therapeutic

PRISTIQ

R69, if you read that mushroom thread, you will see that there are methods of obtaining them other than growing them. And after reading it myself, I have done both. 😊 Definitely worth a try!