Posted by Racer on September 10, 2008, at 10:14:09
In reply to Not sure what to do..?, posted by sam K on September 8, 2008, at 20:32:19
Hm...
So, Pristiq is helpful, although it's not enough, and we don't know what you've taken before, so forgive me if I only repeat meds which have failed in the past.
First, some similarities, so that you get an idea of any reason I might have OK advice for you: my dx's are depression, anxiety, anorexia, and "obsessive compulsive personality traits." (Only because my doctor didn't notice in time to add "and avoidant personality traits -- and maybe dependent personality traits, too since you mention it...") My anxiety is generalized, rather than social, but when it's bad I do have some agoraphobia. My mother has fairly classic agoraphobia, so I'm familiar with it from both sides. I've been on many, many medications and combinations, and found some things helpful, many things partially helpful, and some things really bad. And I would guess that you're afraid of weight gain from meds, and I'd imagine that third dx might suggest to you that I understand that. (I gained between 45 and 70 pounds on the first three antidepressants I took. I leave it to your imagination how that went over.)
Based on what little you've written, it sounds as though what Pristiq is doing isn't really hitting your depression very well. Yes, the anxiety component is prominent, but it sounds as though there's a hopelessness that really indicates a higher level of depression. So, let's look at antidepressants which might help:
Cymbalta is another SNRI; Effexor is the parent molecule to Pristiq. If you haven't tried one of them, it might be worth giving it a shot. Cymbalta is seen by many as the less effective of these two; I found it an easier ride in terms of adverse effects; it's a muddy picture, and if one doesn't work, it's probably worth trying the other as well.
You don't mention having tried any of the TCAs, MAOIs, etc. Virtually all the TCAs are known for causing weight gain in some people. That's individual, though, and those who are at a lower BMI are said to have a higher risk of gaining, and of gaining more weight. In some cases, there are ways to mitigate this gain, but for some drugs it's the nature of the beast -- their effects on weight are direct, they cause metabolic changes which lead your body to change the way it absorbs energy (calories) so addressing the weight gain is much harder. The benefit of the TCAs, though, is that they tend to be focused away from serotonin, and for many people they're a bit more robust. They're often avoided in those with eating disorders, due to the potential cardiac risks.
MAOIs are often known to cause weight gain, AND many doctors are very, very reluctant to prescribe them to anyone with any sort of eating disorder. EMSAM, the new transdermal MAOI, is an exception to this sensible rule, because it does not require dietary restrictions. There are very good reasons for avoiding MAOIs in eating disordered patients. One good and sufficient reason is pretty simple: the goal is an end to obsessive and restricting dietary patterns, and MAOIs necessitate exactly that sort of obsessive and restrictive focus on eating. In addition to this, of course, there are issues like bulimics or other bingers who might trance out and consume restricted foods; the physical damage caused by some EDs could be exacerbated by the drugs; etc.
Wellbutrin is a weight neutral option; although it's officially contraindicated for those with eating disorders. The primary danger with Wellbutrin is for those with bulimic symptoms, and some doctors are willing to prescribe it for some non-purging ED pts. It's not a medication I've seen many people here rave about, but I've taken it for years now -- despite the frustration that it's not the most potent antidepressant I can imagine... I am not in remission from it, and I always have to take at least one other med with it. It's frustrating, and often I fall into a very dark place while on it. Sometimes I wonder if I hold onto it like a security blanket -- but I tried to taper down a couple of years ago, and collapsed, so it's doing something real, even if not quite enough. It could be that a combination of Wellbutrin and low dose SSRI might be a good answer for you, and it's probably worth a try. You'd essentially be combining mechanisms of action in a way that resembles Pristiq pretty strongly. The Wellbutrin would target NE and DA, while the SSRI would cover the serotinergic component. Depending on the specifics of your disordered eating symptoms, that would be my strongest suggestion.
EMSAM is also a strong contender. Many people find it good for anxiety, it avoids the dietary restrictions of other MAOIs, and should be more weight neutral than the other MAOIs.
Remeron is often combined with Effexor, in what's colloquially known as "California Rocket Fuel," but Remeron is also associated with a lot of weight gain. I have yet to hear much about effective strategies to mitigate weight gain on Remeron, but it may be less of a problem at higher doses. If you can get past the fear of weight gain, it might be worth trying it.
For anxiety, the best I ever tried was BuSpar. Many who are used to benzos don't find it helpful, but that's theorized to be related to its subtlety -- with benzos, you can feel them hit shortly after you take them, while BuSpar is much more subtle. It takes a few weeks to ramp up, but at that point those who find it effective say they suddenly realize they're just not all that anxiety. I know that it was by far the best thing I ever took for anxiety -- I get a paradoxical reaction to benzos, and often find that they worsen anxiety for me. This isn't a common reaction to benzos, but anecdotally it's more common in those with eating disorders. BuSpar had no side effects to mention for me, which was another reason I liked it.
Those are all that I can think of right now. If you give some idea of what you've tried, that might help narrow the field.
Good luck.
poster:Racer
thread:851092
URL: http://www.dr-bob.org/babble/20080903/msgs/851320.html