# Best meds for treatment-resistant depression?



## coeur_brise (Oct 7, 2004)

What are some medications that are best for treatment-resistant depression? I think I have that, but I feel embarrassed about asking. I've tried a lot of traditional medications, mostly SSRIs (zoloft, lexapro, effexor, fluoxetine,), but I really didn't stick to any regimen for long. Their effects were either too little or very strong i.e. causing weepiness and even more emotional stress after a few days of taking them... Any suggestions?


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## korey (Apr 25, 2006)

Augmentation of a traditional antidepressant (SSRI, etc.) with a psychostimulant like Ritalin, Adderall, etc. is often effective. There are also MAOI medications, like Parnate, Nardil, EMSAM, etc. They are generally considered to be very effective for treatment-resistant depression. Combining traditional antidepressants is sometimes worth a shot, like with the so-called "California Rocket Fuel" combination of Effexor and Remeron. I've never been on both at the same time, but I've been on each individually, and I imagine together they would pack a nice punch. You could also try adding on a mood stabilizer like lithium or Lamictal (or even Abilify, lol) - they're considered fairly decent for enhancing the effects of traditional antidepressants. There are also tricyclic antidepressants, but they're not really that great due to their large list of side effects.

Aside from those, all I can think of would be to ask your doctor about dopamine agonists otherwise used for restless legs syndrome and Parkinson's disease - Mirapex, Requip, etc. Or drugs for Alzheimer's/dementia, like Namenda (I can't think of anymore in that class right now, lol).


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## Noca (Jun 24, 2005)

http://www.psycom.net/depression.central.resistant.html


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## db0255 (Jul 20, 2009)

1. Prozac
2. Parnate/MAOI
3. Wellbutrin on top of another SSRI


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## jim_morrison (Aug 17, 2008)

I'd probably try an algorithm like this;

1st line: SSRI/SNRI
2nd line: Augment SSRI/SNRI with Wellbutrin, Remeron or Lithium
3rd line: Switch to Clomipramine (TCA)
4th line: Switch to an MAOI


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## crayzyMed (Nov 2, 2006)

korey said:


> Augmentation of a traditional antidepressant (SSRI, etc.) with a psychostimulant like Ritalin, Adderall, etc. is often effective. There are also MAOI medications, like Parnate, Nardil, EMSAM, etc. They are generally considered to be very effective for treatment-resistant depression. Combining traditional antidepressants is sometimes worth a shot, like with the so-called "California Rocket Fuel" combination of Effexor and Remeron. I've never been on both at the same time, but I've been on each individually, and I imagine together they would pack a nice punch. You could also try adding on a mood stabilizer like lithium or Lamictal (or even Abilify, lol) - they're considered fairly decent for enhancing the effects of traditional antidepressants. There are also tricyclic antidepressants, but they're not really that great due to their large list of side effects.
> 
> Aside from those, all I can think of would be to ask your doctor about dopamine agonists otherwise used for restless legs syndrome and Parkinson's disease - Mirapex, Requip, etc. Or drugs for Alzheimer's/dementia, like Namenda (I can't think of anymore in that class right now, lol).


+ 1


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## UltraShy (Nov 8, 2003)

amphetamines


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## crayzyMed (Nov 2, 2006)

UltraShy said:


> amphetamines


Speaking of that, i know you have been on amp for a while now, is it still working as good as the beginning, any tolerance issues? Seems like you are the proof that amphetamine doesnt neceserrely cause a rapid tolerance.


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## silverfish (Sep 18, 2009)

amphetamines do not induce rapid tolerance to all their effects. some people take amphetamines for ADHD for years without problem. The tolerance effect is like the first time you drink coffee - you may feel really hyper and not feel that way the next time you drink it.

Treating Treatment Resistant Depression - goes over 10 ideas/ways to treat resistant depression


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## crayzyMed (Nov 2, 2006)

silverfish said:


> amphetamines do not induce rapid tolerance to all their effects. some people take amphetamines for ADHD for years without problem. The tolerance effect is like the first time you drink coffee - you may feel really hyper and not feel that way the next time you drink it.
> 
> Treating Treatment Resistant Depression - goes over 10 ideas/ways to treat resistant depression


That is probably because the D4 receptor doesnt downregulate in the presence of an agonist, D4 is HIGHLY implicated in ADHD togheter with the dopamine transporter. You do get tolerant to the mood boosting anxiolytic effects in many cases, unless something is taken to prevent/slow tolerance, i say many cases as in ultrashy's example this doesnt seem to be an issue. Which is interesting.


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## RockiNToM (Jun 15, 2009)

jim_morrison said:


> I'd probably try an algorithm like this;
> 
> 1st line: SSRI/SNRI
> 2nd line: Augment SSRI/SNRI with Wellbutrin, Remeron or Lithium
> ...


This.



UltraShy said:


> amphetamines


And this.

These in my opinion are just about the only things that may work after others options have been exhausted.


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## coeur_brise (Oct 7, 2004)

Thanks for the advice guys, but I wasn't prescribed anything else the other day except for another SSRI. No MAOIs or stimulants or anything. I have tried Ritalin in the past, but it just feels like caffeine on crack and that's not such a good feeling with my anxiety. I suppose I'll have to give those other SSRIs in the past another try. I really hate though how medicines like wellbutrin SR and effexor make me want to die by the fifth day of taking them, it just really increases my depression for the first few days, but it's scary enough to want to stop taking them because they just amplify every single emotion I have while I'm on them including the bad ones. I dunno, I was just looking for some kind of medication that didn't make me want to die or had effects that really hardly made a dent on my overall mood.


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## jim_morrison (Aug 17, 2008)

sanria22 said:


> Thanks for the advice guys, but I wasn't prescribed anything else the other day except for another SSRI. No MAOIs or stimulants or anything. I have tried Ritalin in the past, but it just feels like caffeine on crack and that's not such a good feeling with my anxiety. I suppose I'll have to give those other SSRIs in the past another try. I really hate though how medicines like wellbutrin SR and effexor make me want to die by the fifth day of taking them, it just really increases my depression for the first few days, but it's scary enough to want to stop taking them because they just amplify every single emotion I have while I'm on them including the bad ones. I dunno, I was just looking for some kind of medication that didn't make me want to die or had effects that really hardly made a dent on my overall mood.


Have you tried remeron? That one generally lacks the side effects that you described above.


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## Under17 (May 4, 2010)

sanria22 said:


> Thanks for the advice guys, but I wasn't prescribed anything else the other day except for another SSRI. No MAOIs or stimulants or anything. I have tried Ritalin in the past, but it just feels like caffeine on crack and that's not such a good feeling with my anxiety. I suppose I'll have to give those other SSRIs in the past another try. I really hate though how medicines like wellbutrin SR and effexor make me want to die by the fifth day of taking them, it just really increases my depression for the first few days, but it's scary enough to want to stop taking them because they just amplify every single emotion I have while I'm on them including the bad ones. I dunno, I was just looking for some kind of medication that didn't make me want to die or had effects that really hardly made a dent on my overall mood.


How long did you take them for? Did you stop taking wellbutrin after 5 days? Wellbutrin really put me in a whole for about 2 weeks, then I was ok, the first week after taking remeron I thought I was going to go insane and die but it got better. I find it hard to believe that it's purely from the drugs, perhaps I just have some kind of aversion to them, and I definitely have an aversion to getting better because my mind is absolutely stuck in this depressive phase and doesn't know much else. That's the hardest part.


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## coeur_brise (Oct 7, 2004)

Under17 said:


> How long did you take them for? Did you stop taking wellbutrin after 5 days? Wellbutrin really put me in a whole for about 2 weeks, then I was ok, the first week after taking remeron I thought I was going to go insane and die but it got better. I find it hard to believe that it's purely from the drugs, perhaps I just have some kind of aversion to them, and I definitely have an aversion to getting better because my mind is absolutely stuck in this depressive phase and doesn't know much else. That's the hardest part.


Hm to be honest, I don't remember why I stopped taking the wellbutrin, but I did take them longer than 5 days. I just remember having the same feelings as a previous severe depressive episode while I was on it for the first few days, but it did subside after 5 days. The effexor was a bit more extreme and made me feel so bad as to stay inside for a week... but then I didn't take that one for long either.

"Have you tried remeron? That one generally lacks the side effects that you described above."

Well, it's kind of a complicated situation. I wasn't able to get a different medication because of how I never really gave the other medications a fair chance and so my psychiatrist denied giving anything other than an SSRI. She said I never gave them a fair trial and that most of the ones I were prescribed were at low dose thus they could've gone higher (and maybe then it would actually be effective. Zoloft didn't "lift my mood" enough so I stopped that, stopped prozac because I was getting neglectful of my health even though it did show some promise. I did try nortriptyline (my latest trial), but that one didn't improve my mood significantly as I had hoped, so I'm not sure if something like remeron will work. All in all, I will have to wait to try anything else and it's not likely I can try anything else as obviously I've just requested different medicines without going on them for long.


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## silverfish (Sep 18, 2009)

> That is probably because the D4 receptor doesnt downregulate in the presence of an agonist, D4 is HIGHLY implicated in ADHD togheter with the dopamine transporter. You do get tolerant to the mood boosting anxiolytic effects in many cases, unless something is taken to prevent/slow tolerance, i say many cases as in ultrashy's example this doesnt seem to be an issue. Which is interesting.


That's really, really good to know! Thanks! =)


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## Himi Jendrix (Mar 24, 2010)

Remeron or the combo of Remeron and SSRI will improve your mood most certainly. 

Hopefully you can deal with the ravenous hunger of it all. 

Also you must give SSRI's at least 1 month and hopefully 2 months to see if they will work for you. They do tend to increase anxiety and depression in the first 3-4 weeks. At about the 4-5 week mark the good feelings will come in (hopefully). For some people SSRI dont work. I have tried every SSRI and the only ones to work are Prozac and Celexa. 

You should get some benzo's to deal with the SSRI side effects. Most doctors are down with that combo.


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## Edwin (Jun 19, 2008)

Supplement with Omega-3 fatty acid DHA, it's wondrous for both anxiety and depression.


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## yelda (Jun 12, 2010)

most effective antidepressants are tricyclics.
in my opinion, among the tricyclics, most effective one is amitriptyline (elavil)
amitriptyline has a strong anxiolitic effect and I think it is effective for social phobia, either.
one more advantage of amitriptyline: it is very cheap.
effective dose for major depression is 150mg. maximum dose is 300 mg.
side effects can be disturbing though.


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## xJoshx (Apr 29, 2010)

Himi Jendrix said:


> Also you must give SSRI's at least 1 month and hopefully 2 months to see if they will work for you. They do tend to increase anxiety and depression in the first 3-4 weeks. At about the 4-5 week mark the good feelings will come in (hopefully). For some people SSRI dont work. I have tried every SSRI and the only ones to work are Prozac and Celexa.


I agree with this, I am on Duloxetine and it took around 2 months to kick in. Still yet to correct all the problems, takes a while. 
I do think a combination of SSRI + Stimulant would correct the run down effect the SSRI's do cause.


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## Noca (Jun 24, 2005)

yelda said:


> most effective antidepressants are tricyclics.
> in my opinion, among the tricyclics, most effective one is amitriptyline (elavil)
> amitriptyline has a strong anxiolitic effect and I think it is effective for social phobia, either.
> one more advantage of amitriptyline: it is very cheap.
> ...


Yeah Nortriptyline helped pull me into remission from my major depression. Only side effect I get is dry mouth. I'm constantly drinking water.


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