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Author Topic: SNRI vs. SSRI, Is an SNRI promising?  (Read 1067 times)

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Offline dannysmiles19

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SNRI vs. SSRI, Is an SNRI promising?
« on: April 08, 2014, 10:58:42 PM »
Insights, if you respond to this, you know I have been using the SSRI class of drugs since I began treating my depression. Would switching to a drug in the SNRI class promote a better outcome possibly? Like cymbalta or effexor? The withdrawals are horrid I hear, but I need treatment that works. Any insight on the SNRI?
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Offline insights

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Re: SNRI vs. SSRI, Is an SNRI promising?
« Reply #1 on: April 09, 2014, 02:16:25 AM »
Insights, if you respond to this, you know I have been using the SSRI class of drugs since I began treating my depression. Would switching to a drug in the SNRI class promote a better outcome possibly?

Maybe. It is impossible to say. If you've tried 2-3 SSRIs without good results then they are worth considering.

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Like cymbalta or effexor? The withdrawals are horrid I hear, but I need treatment that works. Any insight on the SNRI?

Not Effexor, IMHO. At the doses typically prescribed for anxiety, i.e. <=150mg, it only really functions as a SSRI so probably won't be more effective than them and it can be one of the hardest antidepressants to discontinue. However, its metabolite desvenlafaxine (Pristiq) is worth considering. It is a more potent inhibitor of norepinephrine reuptake than the parent compound and usually easier to quit.

Also consider the tricyclic antidepressants. They typically have milder startup side-effects, usually are relatively easy to quit and can be at least as effective as the more modern antidepressants, and sometimes more so. Their main downside is that they tend to have more ongoing side-effects, particularly dry-mouth and constipation. The one least likely to produce them is desipramine (Norpramin), followed by imipramine (Tofranil) and amitriptyline (Elavil), however, imipramine is the most serotonergic of the three.

Ian
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NOTE: I'm not a doctor, and particularly not yours, so there may be factors I'm unaware of. Therefore all advice is of a general nature and you should consult your doctor before following any of it, especially before changing med doses.

Offline 2sungo

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Re: SNRI vs. SSRI, Is an SNRI promising?
« Reply #2 on: April 09, 2014, 09:05:13 PM »
Hi Danny,
You can follow my experiences with Pristiq on my thread here, I transitioned onto it from Lexapro b/c I was not getting full remission on Lexapro despite the fact it worked wonderfully for about a decade at lower doses than what I took for the last year.  I ran into trouble a week after I quit the Lexapro (had been on 50 Pristiq  for a few weeks while lowering lex), then the doc upped it to 100 (trouble with it is that it is a time release matrix pill and there is no easy way to slightly adjust doses, its lowest amount is 50 mg) but that increased my anxiety after a week and both my blood pressure and heart rate, which are triggers for me.  So we are now trying plan B, 50 pristiq and half a 15 mg pill of remeron to offset some of the pristiq side effects (like insomnia). So far its been a bit rough coming down on the pristiq, but today was overall better than yesterday.  More time is needed to see how it goes and to give the meds a fair trial.  I also take 1 mg of klonopin in divided doses, sometimes a bit more if anxiety is a problem. 
My brother in law has taken Effexor forever for panic disorder and it has worked for years, though it may have raised his sugar and bp levels, which he addresses with other meds, but I am not sure if the Effexor is the only culprit in that.  It has kept him mentally fine though.
As with all of these things, it seems it comes down to individual differences, I await the day when genetic testing will be sufficiently advanced that we can predict with better certainty which medications will work best for a particular individual.  It shouldn't have to be such a crap shoot.
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Offline MLB2805

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Re: SNRI vs. SSRI, Is an SNRI promising?
« Reply #3 on: April 09, 2014, 10:17:34 PM »
I took cymbalta and had yawning and constipation as a side effects,
I also didn't have any withdrawals getting off either
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You don't have to control your thoughts. You just have to stop letting them control you.

Offline dh1972

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Re: SNRI vs. SSRI, Is an SNRI promising?
« Reply #4 on: April 10, 2014, 01:40:24 PM »
Ian,

With the tricyclics you listed, how sedating are they compared to Doxepin and in what order?

I have tried two SSRIs and both gave me so much insomnia I had to discontinue them in the first 10 days.

I have wondered if I should try a tricyclic for anxiety.
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Offline insights

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Re: SNRI vs. SSRI, Is an SNRI promising?
« Reply #5 on: April 10, 2014, 06:40:04 PM »
With the tricyclics you listed, how sedating are they compared to Doxepin and in what order?

Doxepin is the most sedating of the TCAs, nearly as sedating as trazodone. The other 3 are less so, but it is hard to quantify by how much as there is considerable individual variation. Amitriptyline is likely to be the most sedating with imipramine and desipramine some way back in that order, but YMMV.

Ian
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NOTE: I'm not a doctor, and particularly not yours, so there may be factors I'm unaware of. Therefore all advice is of a general nature and you should consult your doctor before following any of it, especially before changing med doses.

Offline dannysmiles19

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Re: SNRI vs. SSRI, Is an SNRI promising?
« Reply #6 on: April 10, 2014, 10:12:34 PM »
Well, I have not achieved full remission from depression in probably two years since my very first Anti depressant Lexapro. The doctor felt that I would do well on viibryd because it is similar to Lexapro but has a Buspar like combination and other properties not typical of the SSRI class. Viibryd has lost efficacy that it had for a short period.

The doctor raised the dose to 50 mg per day and I feel like crap. I hate how I feel every day now, and I wish there were genetic tests to identify the right pill to treat. I have tried multiple SSRI drugs. Prozac, Paxil, Lexapro and Viibryd. Prozac had some kind of bad effect on my nervous system, maybe too high a dose. Paxil didn't work and Lexapro only worked one time around. I have never given a SNRI a chance...and I'm kind of losing my patience with treatment...
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Offline dannysmiles19

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Re: SNRI vs. SSRI, Is an SNRI promising?
« Reply #7 on: April 10, 2014, 10:55:36 PM »
Also, When I asked my doctor many months ago about Zoloft, he completely discouraged the drug. He said if you were on lexapro you don't go from Lexapro to a drug like zoloft. Lexapro is potent so this new medication Viibryd might help you because it's stronger. I guess he felt like Viibryd's properties were something that would work for me.

But I feel like zoloft might be a better drug. Zoloft isn't the same as Celexa, Lexapro or Viibryd right? it has different selectivity and different effects on my depression... so why would he discourage a possible "wonder drug"? Is he right? I know he is a Psychiatrist so he has merits in what he says, but haven't people switched from a drug like lexapro to zoloft because lexapro wasn't working well?

I want to try Zoloft before I go to a different class only because the SSRI class has shown benefit for me...but the lexapro drug and similar drugs have lost efficacy...
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Offline insights

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Re: SNRI vs. SSRI, Is an SNRI promising?
« Reply #8 on: April 11, 2014, 01:15:33 AM »
The doctor felt that I would do well on viibryd because it is similar to Lexapro but has a Buspar like combination and other properties not typical of the SSRI class.  time around. I have never given a SNRI a chance...and I'm kind of losing my patience with treatment...

Viibryd is a SSRI combined with a Buspar like compound. It doesn't do anything that the other SSRIs plus Buspar would do, and unlike Viibryd you can fine tune the amount of Buspar with the others.

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I want to try Zoloft before I go to a different class only because the SSRI class has shown benefit for me.

That is up to you, but you have been on four SSRIs and none have effectively alleviated your depression in the long term. Zoloft doesn't have any magic properties missing in the other SSRIs. It may, or may not work, but given your history I'm not optimistic.

I think you'd be better switch to either a SNRI, except possibly Effexor (venlafaxine) as it is just another SSRI at the lower doses, or a TCA. If anxiety isn't an issue then Wellbutrin (bupropion) should also be considered.

Ian
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NOTE: I'm not a doctor, and particularly not yours, so there may be factors I'm unaware of. Therefore all advice is of a general nature and you should consult your doctor before following any of it, especially before changing med doses.

Offline dannysmiles19

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Re: SNRI vs. SSRI, Is an SNRI promising?
« Reply #9 on: April 11, 2014, 04:33:18 AM »
Wellbutrin was utter crap for me. It seems seratonin is a chemical that's involved. Because of my response to seratonergic drugs. Wellbutrin simply took away appetite and I felt awful. I guess it is time to move onto the next class...I'm kinda scared because I guess I thought ssris were the best treatment
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Offline insights

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Re: SNRI vs. SSRI, Is an SNRI promising?
« Reply #10 on: April 11, 2014, 08:13:17 AM »
I'm kinda scared because I guess I thought ssris were the best treatment

No, not necessarily. They are just the latest type of antidepressants, and they generally have fewer ongoing side-effects, but the double barrel serotonin+norepinephrine (aka noradrenaline) hit of the SNRIs and TCAs has its advantages. Neither of the two best antidepressants for very severe, almost catatonic depression, Effexor (at high doses) and Remeron (mirtazapine), is a SSRI. However, this doesn't mean they are necessarily the best for less severe depression as both have disadvantages too. As I've posted previously, Effexor is just a SSRI at the doses most often prescribed, it can also be very difficult to discontinue, and Remeron is the antidepressant most likely to poop-out, plus it can produce severe carbohydrate cravings.

I think the TCAs have advantages over the SNRIs, but your doctor will probably prefer you try a SNRI first. Either Cymbalta (duloxetine), or Pristiq (desvenlafaxine) would be a good initial choice.

Ian
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NOTE: I'm not a doctor, and particularly not yours, so there may be factors I'm unaware of. Therefore all advice is of a general nature and you should consult your doctor before following any of it, especially before changing med doses.

Offline dannysmiles19

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Re: SNRI vs. SSRI, Is an SNRI promising?
« Reply #11 on: April 17, 2014, 10:58:49 PM »
Hey Ian, I was at the doctor's two days ago and he and I had an interesting meeting. It got to my head a little because he said something like this: Based on your response to the SSRIs and only feeling partial responses, we psychiatrists look at bipolar. You said you have had anger and depression, which is a classic sign of bipolar. and your mood instability.

well, in this meeting, regardless of the bipolar talk, he said he's going to take me off the viibryd and try something new. He said he will put me on cymbalta and lamictal. He said don't worry about labels, let's get you well first. If you do well without the lamictal, then bipolar may not be it. But he wants me to go on lamictal along with the cymbalta.

so now there's a bit of an issue. He said to me to taper off the viibryd starting with 40 every other day for a week and then 10 every day for a week. But do I take the cymbalta tomorrow as I am beginning my tapering process? or do I go through withdrawal during the taper and then start cymbalta? I'm confused. I know you cannot tell me what to do because you are not my doctor. but do you think he meant to take the cymbalta during the tapering process? and if I am bipolar, couldn't the cymbalta give me manic symptoms without the lamictal kicking in for weeks to months?
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Offline insights

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Re: SNRI vs. SSRI, Is an SNRI promising?
« Reply #12 on: April 18, 2014, 12:19:06 AM »
Based on your response to the SSRIs and only feeling partial responses, we psychiatrists look at bipolar. You said you have had anger and depression, which is a classic sign of bipolar. and your mood instability.

If he is suggesting that a lack of response to SSRIs alone indicates bipolar then I don't believe this is right. There are many patients who don't respond well to SSRIs who aren't bipolar. Indeed, it could be argued that the SSRIs are not the best meds for depression. It is no coincidence that the antidepressants proven to be most effective for really deep, almost catatonic depressions aren't SSRIs but the SRNI Effexor (venlafaxine) and the noradrenergic and specific serotonergic antidepressant (NaSSA) Remeron (mirtazapine). SSRIs are the most often prescribed meds for depression not because they are intrinsically more effective than the alternatives, but because their side-effects profile is better, though even this is only partially true for Celexa (citalopram) and escitalopram (escitalopram).

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He said to me to taper off the viibryd starting with 40 every other day for a week and then 10 every day for a week. But do I take the cymbalta tomorrow as I am beginning my tapering process?

I don't understand the first sentence. Are you supposed to take 40mg Viibryd only every second day and 10mg Cymbalta on the alternate days? If so, it seems and odd way to do it, but your psychiatrist knows you and your history so there might be some method to this that I'm unaware of.

Quote
and if I am bipolar, couldn't the cymbalta give me manic symptoms without the lamictal kicking in for weeks to months?

Cymbalta would be no more likely to trigger mania than the SSRIs. Lamictal may be beneficial even if you are not bipolar so is worth a shot.

Ian
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NOTE: I'm not a doctor, and particularly not yours, so there may be factors I'm unaware of. Therefore all advice is of a general nature and you should consult your doctor before following any of it, especially before changing med doses.

Offline dannysmiles19

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Re: SNRI vs. SSRI, Is an SNRI promising?
« Reply #13 on: April 18, 2014, 12:38:30 AM »
What I was saying was he said to take viibryd 40 mg every other day for a week, and then 10 mg viibryd every day for the week after and then stop. my question was do I take cymbalta during this entire process? cymbalta 30 mg during those two weeks?

and he said in bipolar people, they feel like the medication isn't as effective as it once was and in fact it is just a mood shift from the higher mood to the lower mood, not the medication losing efficacy. and he felt the need to prescribe lamictal alongside to prevent depression from coming back... he thinks bipolar is a possibility. He said that bipolar people don't get a full response whereas unipolar patients don't get mood instability and even out when the medication kicks in. but I know partial response isn't indicative of bipolar.

he feels like the mood instability is an existing problem and that a mood stabilizer along with the viibryd could have been the right way to go but he was willing to switch me to cymbalta to give it a fair trial. but mood instability happens during clinical depression recovery as well, right? I'm kind of lost as to whether or not I am more on the bipolar spectrum or more towards unipolar.
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Offline insights

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Re: SNRI vs. SSRI, Is an SNRI promising?
« Reply #14 on: April 18, 2014, 02:29:14 AM »
What I was saying was he said to take viibryd 40 mg every other day for a week, and then 10 mg viibryd every day for the week after and then stop

Okay. It is still an odd way of doing it. The preferred way would be to taper the daily dose every 3 days or so, but there might be a reason why he wants it done this way.

Quote
my question was do I take cymbalta during this entire process? cymbalta 30 mg during those two weeks?

If he didn't explicitly say so then I'm guessing he wants you off the Viibryd before starting the Cymbalta. But you should get a clarification on this.

Quote
I'm kind of lost as to whether or not I am more on the bipolar spectrum or more towards unipolar.

I can't answer that. Nor will the results of taking Lamictal necessarily prove it as it can have positive effects on depression even in those that aren't bipolar.

Ian
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NOTE: I'm not a doctor, and particularly not yours, so there may be factors I'm unaware of. Therefore all advice is of a general nature and you should consult your doctor before following any of it, especially before changing med doses.

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