# Let's talk ultimate medication combos



## jaiho (Feb 14, 2015)

This stuff fascinates me, so here's what ive found in my research. The two top psychiatrists to listen to IMO, Dr Stahl & Dr Gillman. Perhaps more so Gillman, due to some shortcomings with Dr Stahl's "California Rocket Fuel" combination (Effexor + Mirtazapine), mainly because current SNRIs are not "true" SNRIs, but mostly SSRIs.
To get a true SNRI we either have to go back to the old TCAs like clomipramine, which can have quite uncomfortable side effects, or use a combination method.

Sertraline + Nortriptyline:
This achieves a far stronger SNRI than any SNRI on the market, even more so than the old TCAs.

Nortriptyline is a NRI dominant TCA, with weaker Serotonin reuptake inhibition. It has minimal side effects and minimal sedation.
It also has 5HT antagonist properties that further its efficiency.

Sertraline is the SSRI we should all know about, and one of the only SSRIs that increase extracellular dopamine. Though this may only become evident as high doses.

So in effect, we have an SNDRI (Serotonin, Norepinephrine, Dopamine reuptake inhibitor, or, triple reuptake inhibitor) with 5HT antagonist properties that can likely block sexual side effects, & provide a strong anti depressant & anti anxiety response.

If this combo fails, then its MAOI time.
Parnate & Nardil.

Doses can be ramped quite high, but this might not be needed with augmentation strategies. Nortriptyline can also be used as a bridging med, moving from Sertraline to Parnate.

So Parnate + Nortriptyline, likely the end game for treatment resistance.


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## SFC01 (Feb 10, 2016)

See where you are coming from Jaiho with your first combo, and if I had to, and I mean "had to" use an SSRI again, then Sertraline plus a TCA would be where I would go. I just don't believe the DRI effect of Sertraline is in the least bit noticeable, from my experience at 50mg right up to 250mg. I much prefer the dopamine action from 5HT antagonism. 

So I take Nardil 75mg, Trazodone 150mg and Amitriptyline 20mg and its extremely effective. I`m so self-confident I`ll take you all on !! 

Nardil speaks for itself. The trazodone has some antagonist action on 5ht2a and @ 150mg, some effect on 5ht2c, and hopefully being on just 150mg will keep me away from any SRI action. It also helps me reduce the number of Nardil early awekenings, which I do love, but after a few days they can catch up on you and it helps firm things up if you know what I mean  (Not that I need it haha ).

The low dose of amitriptyline somehow just rounds things off nicely, increased energy, mood and quite hedonistic for some reason. As per Nortriptyline (its metabolite) I know it has some 5ht receptor stuff but not sure what dose that kicks in at.


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## swim (Apr 4, 2011)

jaiho said:


> This stuff fascinates me, so here's what ive found in my research. The two top psychiatrists to listen to IMO, Dr Stahl & Dr Gillman. Perhaps more so Gillman, due to some shortcomings with Dr Stahl's "California Rocket Fuel" combination (Effexor + Mirtazapine), mainly because current SNRIs are not "true" SNRIs, but mostly SSRIs.
> To get a true SNRI we either have to go back to the old TCAs like clomipramine, which can have quite uncomfortable side effects, or use a combination method.
> 
> Sertraline + Nortriptyline:
> ...


what about paroxetine nortip combo? what about weight gain as prominent side effect?


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## swim (Apr 4, 2011)

I think edronax/davedax/vestra added to a SSRI would cause less side effects than a TCA combo and comparable NRI efficacy.


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## jaiho (Feb 14, 2015)

Paroxetine + nortrip is still good, though would need to check the interactions and nortrip dose adjusted.
Reboxtine is nowhere near as efficient, Nortriptyline has 5HT antagonist action that furthers the SSRIs effiency (5ht2a / 5ht2c)


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## swim (Apr 4, 2011)

jaiho said:


> Paroxetine + nortrip is still good, though would need to check the interactions and nortrip dose adjusted.
> Reboxtine is nowhere near as efficient, Nortriptyline has 5HT antagonist action that furthers the SSRIs effiency (5ht2a / 5ht2c)


do you refer to the 2D6 liver enzyme right? Sure zoloft has less drug interactions, unfortunately it failed on me.
Ritalin instead would not mess with liver enzymes if combibed with paroxetine.


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## jaiho (Feb 14, 2015)

swim said:


> do you refer to the 2D6 liver enzyme right? Sure zoloft has less drug interactions, unfortunately it failed on me.
> Ritalin instead would not mess with liver enzymes if combibed with paroxetine.


Check with Gillman, he would know.
I know fluoxetine triples Nortrip blood level. Sertraline doesnt increase nortrip blood level much at all.
It goes well with any SSRI, just the dosage needs to be adjusted.


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## watertouch (Nov 4, 2013)

Interesting thread... Yeah Stahl is a bit bias, every medicin works great! :sus
Gillman is more openly questions the efficancy of some meds, specially when it goes against his experience as a practitioner, and research that aren't sponsered by some drugmanufacture.

For example reversible MAOA-inhibitor Aurorix/moclobemide. No Pdoc have really found it helpfull.
Ive had 3telling me that it never helped anyone...
Yeah on the paper and in many textbook it has a high evidens strenght for being effective in Social Phobia/social anxiety. I doesn't work good.

Haven gotten SS/ST from a Pdoc "specialist is pshychiatry" which combined the TCA Clomipramine 150mg with Zoloft 200mg.
It didn't "cure" me, so the Zoloft dose was decreased to 75mg and 20mg fluoxetine was added. So Clomipramine 150mg+sertraline 75mg+fluoxetine 20mg...:clap

Weird combos with the TCA-clomipramine is used, but usually for treatment resistent OCD. An SRI is usually added and its dosed up till the point the patient experience "mild" symtoms of SS/ST
http://www.psychiatrist.com/jcp/article/Pages/2013/v74n12/v74n1201.aspx
With close supervision!

But we are not talking about: Clomipramine 150mg+sertraline 75mg+fluoxetine 20mg....:grin2:

The good thing with Nortriptyline is that it can be messured in blood for its concentrationlvls
"The Therapeutic plasmaconcentration for nortriptyline is 50-150ng/ml(Eq 200-600nmol/l)"

From the Swedish prescribersguide FASS.
http://www.fass.se/LIF/product?3&userType=2&nplId=19650520000011&docType=3

*
*


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## watertouch (Nov 4, 2013)

swim said:


> I think edronax/davedax/vestra added to a SSRI would cause less side effects than a TCA combo and comparable NRI efficacy.


Naa well yes sure your right about side-effects.
The ones potent enought is probably Edronax and Strattera.
Of them ive only tried Edronax/reboxetine ehh didn't really do much, but making me sweat more and causing ejaculation before climax... (Was kinda weird at first)...

I found the TCA- Nortriptyline working good overall, for anxiety and such... But thats more as a "single agent" use, it can cause hunger and "carbohydrates crawings", it gives one energy to bake a cake!. Its altough kinda the "wrong type of good, energy" :grin2:

A Combo of SSRI+ Edronax would probably be better then a combo of SSRI+mirtazapin/mianserin... 
Unless the mirtazapin is used for sleep, or such. Im basicly agreeing with you!

SSRI+Nortriptyline, would probably be good after first trying Edronax.

I have however tried Nortriptyline some 4-5times (with augments) So im abit bias, i have only tried Edronax 1 time...


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## Tone (Oct 12, 2012)

Good Thing all 7 billion humans on earth are miraculously immune to a Mu/Kappa pathway dysfunction ; at least that narrows things down to what monoaminergic combo will work.


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## jaiho (Feb 14, 2015)

watertouch said:


> Naa well yes sure your right about side-effects.
> The ones potent enought is probably Edronax and Strattera.
> Of them ive only tried Edronax/reboxetine ehh didn't really do much, but making me sweat more and causing ejaculation before climax... (Was kinda weird at first)...
> 
> ...


Stahl loves the SNRI + Mirtazapine combo.. but i dont understand how he can tout SNRIs as being actual SNRIs.. the binding is so weak.

Another combo i would like to try is Brintellix + Nortriptyline.. For that 5ht1a partial agonism.


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## watertouch (Nov 4, 2013)

jaiho said:


> Stahl loves the SNRI + Mirtazapine combo.. but i dont understand how he can tout SNRIs as being actual SNRIs.. the binding is so weak.
> 
> Another combo i would like to try is Brintellix + Nortriptyline.. For that 5ht1a partial agonism.


One kinda have to, if the "flag ship" Effexor doesn't work. and the "nassa" Remeron/mirtazapin was kinda new (mianserin been around for years tough) not much difference in effect from the two, or well one is this new class of drug "nassa" .WOW:boogie

There have been some reports of the use of the betablocker pindolol as augmentation.(saw it in a textbook)
https://en.wikipedia.org/wiki/Pindolol
When starting an AD, it was thought that its effects on 5HT1A receptor would both accelerate the onset of SSRI o such meds" and also enhenche the effect...

I don't recall if there was any strong eveidens for that combo, but it just popped into my head when thinking of the 5HT1A receptor. :grin2:


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## wealldead (Jun 20, 2014)

Damn Clomipramine 150mg+sertraline 75mg+fluoxetine 20mg are safe ??? 2ssri cause you serotonic syndrom no ?


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## watertouch (Nov 4, 2013)

wealldead said:


> Damn Clomipramine 150mg+sertraline 75mg+fluoxetine 20mg are safe ??? 2ssri cause you serotonic syndrom no ?


No its not safe, it did cause SS... And 3 "SRI"(serotonin reuptake inhibitor) with the TCA clomipramine counted.

The title "Specialist in Psychiatry" is a joke!


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## watertouch (Nov 4, 2013)

Anyway thinking of a combo with T3(liothyronine) some 50mcg/day and maybe something else like Nortriptyline... 
Maybe something for the Dopamine...

The Dopamine Agonist- Pramipexole has shown some new light on treatment for Anhedonia.

http://www.medscape.com/viewarticle/861659

Interesting to see Dr. Mariano commenting on it, can't wait till his homepage is back up!!! just 12 days and 17 hours...
http://definitivemind.com/


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## Gillman fan (Sep 24, 2016)

Jaiho: 5ht1a agonism of Trintellix is awesome, for a few days. This receptor develops tolerance rapidly - more rapidly than other receptors. No stable way to achieve response here. I tried it, the pro social feeling is very nice. I think Trintellix is garbage - it is just another SSRI with enough receptor activity to create a marketing buzz. 

One thing I wanted to add here is low dose lithium. Higher dose used for bipolar may cause thyroid problems, but you can use lower dose for augmentation. It is neuroprotective and it has been shown in studies that it does not "poop out." Used like this, Lithium is an augment in its purest sense - it does nothing on its own but theoretically can complement any med. 

Dopamine agonism is nice, SSRI generally does nothing for anhedonia. But I doubt that pramiprexole holds a candle to Parnate in terms of potency. 

Noritryptiline also is a cool addition to MAOI because it blocks the cheese reaction. 

Ketamine absolutely potentiates all these monoaminergic mechanisms of action. Other NMDA receptor antagonists do too but probably to a lesser extent. 

As far as opiod agonism, I consider this experimental. I am sure it can help some people. IMO it takes time before new treatments can prove their worth. Scopalamine is another novel mechanism of action that has shown some promise but I don't think has proven efficacy yet.


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## zeusko87 (Sep 30, 2014)

Nardil + Tianeptine is a great combo for atypical depression and social anxiety. I have ordered Tianeptine from e-bay and it works much better with Nardil than as monotherapy.

I can confirm that there are no problems regarding SS with this combination because unlike other TCA"s Tianeptine is not a monoamine reuptake inhibitor. Actually, it lowers serotonin. Regarding side effects there is only troubles with constipation and nausea for the first few days.

Tianeptine/Nardil works great for my anhedonia and luck of motivation. Better than anything i tried before

From https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4312778/

_*The combination of tianeptine and monoamine oxidase inhibitors has no apparent contraindication.

*There may be a unique benefit to the combination through their direct and indirect effect on enzyme monoamine oxidase located on the outer mitochondrial membrane.
*There are many patients suffering from depression, who require polypharmacy to approach or achieve remission._

http://www.minervamedica.it/en/journals/minerva-psichiatrica/article.php?cod=R17Y2013N03A0185
_
" MDD is complicated by recurrence and disability. Treatment of MDD may include a monoamine oxidase inhibitors (MAOI) or tianeptine. There are no known adverse interactions between these drugs. Case studies show that combination therapy with MAOI and tianeptine may be useful in safely achieving remission in patients who suffer MDD that is resistant to treatment."_

https://www.ncbi.nlm.nih.gov/pubmed/23048001

"_The patient had further improvement of depression symptoms after addition of tianeptine. No adverse events were evident. The combination of MAIOs and tianeptine may be effective for refractory major depressive disorder."_

http://www.omicsgroup.org/journals/...nt-depression-2167-1052-1000189.php?aid=58366
_
"The past 2 years, P3 has remained in partial remission. There have been no adverse events associated with the current combination of tranylcypromine 120 mg daily, tianeptine 37.5 mg daily, modafinil 400 mg daily, and an atypical neuroleptic. Reduction in the doses of either tranylcypromine or tianeptine induces depression, and reduction or elimination of modafinil causes lethargy. Historically, her CGI-S has fluctuated between 4 (during her twenties) and 7 (during her mid-thirties). As a result of treatment, her current CGI-S has been consistent between 2 and 3 for more than 2 years."_


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## SFC01 (Feb 10, 2016)

Hi zeusko87, is the ebay vendor reliable? Would you be able to pm me the vendor name please?


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## watertouch (Nov 4, 2013)

Ive tried Tianeptine as augmentation to MAOI-Parnate, also without problems... 
No side effects, altough ive heard of some getting raised BP when combining with Nardil, so maybe a caution should be added... 
I tended to ramp up the Tianeptine dose a bit..

Otherwise from what ive read it takes some time for it to work...

Its some interesting info on Reddit.com about Tianeptine.


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## jaiho (Feb 14, 2015)

I would have stayed on Parnate + Nort if the sexual dysfunction wasnt so severe... so it was back to SSRI + Nort.
I wonder what could be added to such a combination. MAOIs are less able to be augmented.


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## wealldead (Jun 20, 2014)

Ok water touch, this what i was thinking.... So, the problem for me is that the only treatment that worked during 3 months (3years ago now)was the dangerous combo of : MARSILID(MAOI )(300MG)+PAROXETINE(60MG)+RITALINE 60MG : and everybody is chocked that i didn't die. So i wondering if I just take again not a Maoi with a ssri but just two ssri (minimal dose of each ad ?)at low dose with ritalin low dose is powerfull than a lonely ssri ?


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## jaiho (Feb 14, 2015)

You'd be better off adding an NRI selective TCA to that combo instead of another SSRI or MAOI, i'd suggest, wealldead.


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## wealldead (Jun 20, 2014)

Hi 

Nri or Tca =tryciclics, why ? they act same on serotonine as ssri, by different way but they can cause syndrome serotonic as two ssri together, nope ?


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## watertouch (Nov 4, 2013)

wealldead said:


> Hi
> 
> Nri or Tca =tryciclics, why ? they act same on serotonine as ssri, by different way but they can cause syndrome serotonic as two ssri together, nope ?


I do remember we talked abit about some weird combo you where trying some year ago!! 

Naa different TCA have different effect... I like Nortriptyline, It has somewhat "low" Anticholinergic side effects (dry mouth, eyes, fuzzy head n such)...

I wouldn't go high on Paroxetine, because it inhibits and use the same liver enzyme CYP2D6... 
And its kinda potent 20mg gives and blocking effect of 80% of SERT... 
The other effect Paroxetine has is a litte NRI and some anticholinergic effects.... 
So basicly you shouldn't really need higher doses if you are augmenting it with anything that work like that. Or also use the CYP2D6 liver Enzyme....

The Most potent TCA for SRI (serotonin reuptake inhibitor) is Clomipramine and Imipramine, some of the other are somewhat "safe" to mix...See Gillman TCA review for a more comprehensive overview
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2014120/

Long time no see tough!!!! How you doin, and whats you been up to Welldead???. Feel free to PM me!

Best wishes!!! Alex


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## wealldead (Jun 20, 2014)

ahah watertouch yeah I remember, talking about sildenafil + ritaline lol, all that crap are finished because of my OCD, my girl friend replaced me.

I don't have any treatment of medication since 1year and 2 month, because Nardelzine cause me a huge decrease of my testosterone level(was being fat as a girl, tired as a grandmother ...).

But, now, absolutly no mood, I need to re-build my life ( worst depressed and obssesed anxious I am since 3years).

I read on wikipedia Nortriptyline can create heart attack ? Nortriptyline is known to make weith gain ?
20 mg paroxetine block 80% sert !? 

Yes you right for CYP2D6, but if I remember my body easily eliminates Drug Substances. So the liver inhibts enzyme of CYP2D6 could make that the 2nd medication coupled with paroxetine is more effective ? But inevitably it gets more dangerous, maybe for the renal function ?
Is because of this inhibition of CYP2D6 that paroxetine is known to be more effective?

Finally, I am seduced by taking sertraline + nortriptyline (considering it is safer than 2 ssri or 1maoi and ssri ?)

And considering that nortriptyline is more effective to recapture serotonine than amitriptyline :

Receptor Ki [nM][Note 1]
(amitriptyline)SERT 3.13 NET 22 [30][31] Ki [nM][Note 2]
(nortriptyline)[30][31] SERT 16.5 NET 4.37

+ it's difficult for me to believe that "Nortriptyline is a NRI dominant TCA, with weaker Serotonin reuptake inhibition. It has minimal side effects and minimal sedation.
It also has 5HT antagonist properties that further its efficiency." in one hand wikiepdia shows that it's a strong sertonin reuptake inhibition and the other hand the author jaio of this post says that it has 5HT antagonist which prevent sexual dysfuction made by Serotonin reuptake inhibition ??

But, I still seduced by trying the two meds for my SA : but I will regullary make blood test check on my T level and prolactine, follow my weight and blood pressure(because Syndrome serotonine act by increaser heart rate and blood pressure if I remember ?)

Thank you

2nd damn : I read that nortriptyline can inhibit some "microsomal ?" testosterone of rat :
https://books.google.fr/books?id=m1...zAG#v=onepage&q=Nortriptyline inhibit&f=false


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## wealldead (Jun 20, 2014)

Oh sorry I understood :

Receptor Ki [nM][Note 1]
(amitriptyline)SERT 3.13 NET 22.40][31] Ki [nM][Note 2]
(nortriptyline)[30][31] SERT 16.5 NET 4.37

more the number is small, more the drug act on the reptak of sert or NET ? so amitriptyline is a powerfull serotoninergic med.


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## UKguy (Sep 30, 2013)

What about so called "welloft" ? Wellbutrin (bupripion) and Zoloft (sertraline)... I hear it is a reasonably well used combo. Must be quite simulating I would have thought.


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## wealldead (Jun 20, 2014)

it seems sertraline has al ready good afinity with DAT, however I would prefer ritaline than bupropion...


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## wealldead (Jun 20, 2014)

Iheard Nortriptyline alows to coutner de sexual side effects of SSRI : it s hard to believe...


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## watertouch (Nov 4, 2013)

wealldead said:


> Iheard Nortriptyline alows to coutner de sexual side effects of SSRI : it s hard to believe...


Ehh trying to get your questions answered... Ehh Cyp 2D6 is used by paroxetin, and it also inhibit the enzyme, so higher dose paroxetine=higher use of CYP2D6, so higher dose really is higher dose since it inhibits its own breakdown.

(other stuff that needs 2D6 to get broken down will get increased)/or meds like Codeine wich need 2D6 to get "converted/metabolised" to morfin will be decressed/ wont work that well...

MAOI+SRI is a very dangerous combo. I was actually just the other day talking about it with Dr. Ken Gillman. 
(ive bought a "new" textbook from the Norweigan psychopharmacologist author Odd Lingjaerde, Psykofarmaka 2015)... (wich mentioned the combo).

So one should stay away from that combo!

Nortriptyline heart attack, ehh its abit different types, n mechanism, all from the Anticholinergic side effects, to calcium channels to NRI(noradrenaline reuptake inhibitng) actions or QT...

Weight gain.. ehh it can cause one to get increased "crawing" for sugar or such "carbohydrates"... 
I recall one instance it gave me the energy to actually bake a cake... (its tough kinda the wrong energy) :grin2:

And sorry to hear about you being replaced, hopefully you can replace her!!!


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## wealldead (Jun 20, 2014)

watertouch said:


> Ehh trying to get your questions answered... Ehh Cyp 2D6 is used by paroxetin, and it also inhibit the enzyme, so higher dose paroxetine=higher use of CYP2D6, so higher dose really is higher dose since it inhibits its own breakdown.
> 
> (other stuff that needs 2D6 to get broken down will get increased)/or meds like Codeine wich need 2D6 to get "converted/metabolised" to morfin will be decressed/ wont work that well...
> 
> ...


lol you cook some cakes ahah

ok it's for all TCA so... plus Anticholinergics effects are not my friends, feel like a slow autist !

Yes I understood, it's metabolized by CYP2D6 and also inhibts CYP2D6 lol, so at one time you have difficult to evacuate paroxetine and any king of med which is metabolized by CYP2D6.

Yes thank you, I hope to replace her !


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## wealldead (Jun 20, 2014)

jaiho said:


> I would have stayed on Parnate + Nort if the sexual dysfunction wasnt so severe... so it was back to SSRI + Nort.
> I wonder what could be added to such a combination. MAOIs are less able to be augmented.


Before, replace Parnate by a ssri, you should try to lower the dosages of parnate and augment Nort ? or take one 1/2days your parnate pills .
what were your dosage ?

And it was effective for S.A and OCD ?

You didn't have problem for food ?

Thank you


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## watertouch (Nov 4, 2013)

wealldead said:


> lol you cook some cakes ahah
> 
> ok it's for all TCA so... plus Anticholinergics effects are not my friends, feel like a slow autist !
> 
> ...


yes that how paroxetine and CYP2D6 works...

cake, and cake, don't know the word for this, " a roll"


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## watertouch (Nov 4, 2013)

(i did not bake the thing above) *


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## UKguy (Sep 30, 2013)

Venlafaxine (effexor) and Mirtazapine (Remeron) is sometimes used as well.


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## FewFriendsRob (Mar 28, 2013)

Great post...thanks for sharing.


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## zeusko87 (Sep 30, 2014)

For me the most effective combos are:

*Nardil+Tianeptine+Caffeine* (3 times a week) -most helpful combo for depression 
*Nardil+Lyrica+Caffeine* (2-3 times a week) -most helpful combo for social anxiety
*Nardil+Modalert+Caffeine* (2 times a week) - most stimulating combo
*Nardil+Phenibut* (once a week) - most euphoric combo


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## UltraShy (Nov 8, 2003)

"California Rocket Fuel" would NEVER top Parnate if not for the StarD trials using a wussy little mean dose of only 39 mg of Parnate.

Push that Parnate to 120 mg and watch it beat all the "new & improved" ADs, and do so with absolutely no side effects.

Want even better? Toss in Nuvigil.

For a year I took a prescribed dose of 120 mg Parnate (yes, 12 pills a day). And I've tried up to 200 mg daily, which didn't do any more than 120 mg.

I switched to Nardil 90 mg, which is definitely more effective for anxiety. I used to be the guy to afraid to even make a phone call. I went from that to working with a Realtor and buying a rather nice home. So Nardil has side effects that include constipation and the purchase of a $331,000 home.

Nuvigil, in addition to a wakeful effect, has a clear anti-depressant effect. It also has a VERY clear laxative effect, though that should be no problem as Nardil is VERY constipating.

Problem: your insurance company won't want to pay for Nuvigil as it's has an obscene price of $6,000 per year. I fought my insurance company and won, pointing out that other options to fight my excessive daytime drowsiness -- Ritalin & amphetamines -- could produce DEATH in an MAOI patient. They were nice enough that they didn't want to kill me, so they granted me a medical exception to get my Nuvigil covered.


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## wealldead (Jun 20, 2014)

UltraShy said:


> "California Rocket Fuel" would NEVER top Parnate if not for the StarD trials using a wussy little mean dose of only 39 mg of Parnate.
> 
> Push that Parnate to 120 mg and watch it beat all the "new & improved" ADs, and do so with absolutely no side effects.
> 
> ...


So, parnate wasn't effective for anxiety and you have taken during 1 year ? It was effective for what ? or just less effective than nardil for anxiety ? and for OCD ?

I hope Parnate didn't make you as anxious as you are telling that you were afraid to make a phonecall ?

And the gaba effects of Nardil don't discomfort you ?


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## Schneegestein (Mar 22, 2016)

Hi !

Yeah i take both Parnate and Bromantane with no interaction.

My best combination was/is MAOI + Amitriptyline ( for sleep ), Bromantane, Emoxypine, Dexamphetamine and and and... i added many other medications for the ultimate effect against Anergic Depression, OCD and Anxiety


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## imwiththedj (Dec 16, 2011)

As a doctor, I'd like to be creative...

Lexapro + Respidal, 

Celexa + Seroquel

Effexor + Abilify...


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## 546617 (Oct 8, 2014)

imwiththedj said:


> As a doctor, I'd like to be creative...
> 
> Lexapro + Respidal,
> 
> ...


damn u doctors suck. if i already wasnt, just put me on nardil and we good bro!


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## Schneegestein (Mar 22, 2016)

xD i agree


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## wealldead (Jun 20, 2014)

Schneegestein said:


> Hi !
> 
> Yeah i take both Parnate and Bromantane with no interaction.
> 
> My best combination was/is MAOI + Amitriptyline ( for sleep ), Bromantane, Emoxypine, Dexamphetamine and and and... i added many other medications for the ultimate effect against Anergic Depression, OCD and Anxiety


I'm a lil bit scared of meds from Russia ahah>


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## Gillman fan (Sep 24, 2016)

So here is one out of left field that I like, although probably not 100%:
Clomipramine + dextroamphetamine + Pramipexole + Apripazole. 
This is the combo of Dr. Jan Fawcett. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5033120/. Much like Dr. Gillman, he has an extra focus on the role of dopamine.

I think I will tinker with one or two more meds before I start afresh in a different direction. 
Supposedly the D3 receptor is the best target for anhedonia / low energy. I haven't researched this much.

And yes this is a bit of a necro but it is a perennial topic and we haven't had any more recent discussions.


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## jaiho (Feb 14, 2015)

Haha that combo sounds nuts, though im not sure why the Apripazole is in there, as the Pramipexole, and Clomipramine is covering most of what it's doing.

The only danger i can see in excessive dopamine transmission is the chance of psychosis. I remember from my Parnate + Nort days, if i smoked abit of grass i'd start hearing voices or music that wasn't there, and i've never had psychotic symptoms my entire life.


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## Gillman fan (Sep 24, 2016)

I don't understand the apriprazole either. And I would rather be using Parnate than Clomipramine. 

I think my next drug trial will be Pramipexole. This Jan Fawcett guy cannot be accused of practicing "anodyne" medicine as Dr. Gillman accuses his profession of doing. I saw a power point covering individual patients, very treatment resistant, I remember a few responded to Pramipexole even though they failed a Parnate trial (or didn't get full relief).

Mainly targets D3 receptors, which are supposed to be linked to motivation/pleasure. 

Anyway it is just nice to know that there are other Doctors out there fighting the good fight instead of putting patients on the SSRI carousel.


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## watertouch (Nov 4, 2013)

Hey! Oh! Let's GO!!!

Need something or its like Nardil for me.


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## jaiho (Feb 14, 2015)

Cymbalta + Geodon

I like the look of this combo

SNRI + the Geodon has nice properties for an anti psychotic.
5ht1a agonist, 5ht2a 5ht2c antagonism. Not too strong as an antihistamine.

Only downside is the dopamine antagonism.

Abilify would be a good swap out, but 5ht2c agonist doesnt sound good either..

Other than that... SSRI + Nortriptyline, or
Jump back on MAOIs.


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## watertouch (Nov 4, 2013)

Maybe something like TCA- nortriptyline + SSRI sertraline+ Modafinil 200-400mg/day. and T3 (liothyronin)

Trazodone for sleep.

Betablocker propranolol as needed for heartracing or panic attacks,


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## Hordak (May 5, 2017)

watertouch said:


> No its not safe, it did cause SS... And 3 "SRI"(serotonin reuptake inhibitor) with the TCA clomipramine counted.
> 
> The title "Specialist in Psychiatry" is a joke!


who is a so called "specialist" in Psychiatry?


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## watertouch (Nov 4, 2013)

Duckbruck said:


> who is a so called "specialist" in Psychiatry?


Im guessing it comes from the statement that it take 10.000hours
"Malcolm Gladwell says that it takes roughly _ten thousand hours_ of practice to achieve mastery in a field"

So after practicing medicine and in the psychiatric field for some time the title expert or specialist is added. 
Specialist is not an "offical" title...


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## Hordak (May 5, 2017)

watertouch said:


> Im guessing it comes from the statement that it take 10.000hours
> "Malcolm Gladwell says that it takes roughly _ten thousand hours_ of practice to achieve mastery in a field"
> 
> So after practicing medicine and in the psychiatric field for some time the title expert or specialist is added.
> Specialist is not an "offical" title...


ok, thanks 

I am on Sertraline 50mg and it is working quite well, but I have side effects that I won't tolerate forever...
# no appetite (that's the worst part about my side effects. I am already quite skinny)
# moderate insomnia
# hot flashes (very annoying especially now when it's hot outside.)

Not sure about changing it to another standalone AD or augmenting the Sertraline with something like Mirtazapine / Maprotiline / Nortriptyline etc.
There are sooo many possibilities ^^

My next appointment is in 3 weeks, I will have to come up with suggestions about my future AD regimen, because I don't want to tolerate that side effects any longer. I am becoming anorexic (60kg @ 5'9 right now, male). Maybe a combo would be the best for me, considering that the Sertraline works quite well on my depression & social anxiety so far and I am still on a relatively "low" dose.


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## Sweeto (Jul 21, 2015)

If one has very severe SA (horrible fear), it's almost impossible to treat it by meds beside really strong ones such as MAOIs, opiates, stimulants.

Fear is one of the strongest feelings one can experience in the life. Without fear ppl wouldn't survive in the past in the wild...

Anyway I will mention some of them which had worked for me:

Tramadol + Klonopin (anyway not long term solution)
Ritalin + alcohol (super boost for self confidence)
Cocaine (even it's not a med but there isn't so many meds which had worked for me so therefore)

The key to treat anxiety generally is to find out how anxiety works and try different therapies, that's the only one long term solution according to me.


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## watertouch (Nov 4, 2013)

Duckbruck said:


> ok, thanks
> 
> I am on Sertraline 50mg and it is working quite well, but I have side effects that I won't tolerate forever...
> # no appetite (that's the worst part about my side effects. I am already quite skinny)
> ...


This is just an FYI about your sertraline dose.
50mg of Zoloft / sertraline usually block the tansporter some 80% so going higher might actually just cause side effects... It might however be tried.

Augmentin it with Mirtazapine actually seems like a good idea, the Mirtazapine some 7.5-15 or even 30mg towards night might help with the insomnia ( lower doses are actually more sedating since when going higher it increases noradrenaline signaling).

The TCA- Nortriptyline could also be used, but will probable not work that well for the insomnia, the TCA- Amitriptyline might be more effective (this med actually gets metabolized to nortriptyline, but have stronger anticholinergic effects and such)

Alot of medicines that increase serotonin can cause these hot flashes or increased sweatning...

Both Mirtrazapine and Nortriptyline can work here since they actually have a "blocking" antagoinst effect on some Serotonin receptors...

mirtazapine also usually increase "hunger"... So it would probable be like hitting 3 flyes at one strike, with adding some 7.5-15mg mirtazapin towards night!

If mirtazapin works somewhat for the sleep, and the whole combo works ok but you still suffer from sweatning... something like Oxybutinin can be tried at low doses, like 2.5mg x2 /day.

Or switch the mirtazapin to some 25-50mg amitriptyline towards night


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## watertouch (Nov 4, 2013)

Sweeto said:


> Ritalin + alcohol (super boost for self confidence)


Yes Ritalin have been noticed to be effective for the mood. For me however i needed an "higher" dose, but the whole DRI things is interesting.


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## Hordak (May 5, 2017)

Thanks for your reply :thanks



watertouch said:


> This is just an FYI about your sertraline dose.
> 50mg of Zoloft / sertraline usually block the tansporter some 80% so going higher might actually just cause side effects... It might however be tried.


Are there other receptors / transporters, that are affected only at higher doses?
Or why do people take it up to 100mg, 150mg or even 200mg? I've even heard of 300mg and 400mg :um



watertouch said:


> Amitriptyline might be more effective (this med actually gets metabolized to nortriptyline, but have stronger anticholinergic effects and such)


Do classical TCAs in general have more severe side effects than SSRIs?
That's what I often hear in the media, but is it true?

I was already thinking about trying a standalone TCA like Clomipramine, Amitriptyline, Trimipramine... but I am not sure about it. Most docs only prescribe SSRIs and are afraid of anything else *lol*

Maprotiline as standalone AD is also very interesting. It's a rather well balanced drug.



watertouch said:


> Alot of medicines that increase serotonin can cause these hot flashes or increased sweatning...


Luckily I don't sweat a lot. (I am not sure why, maybe I don't have many sweat glands? :sus )
I just become red and get rid of that heat via infrared radiation or so ^^



watertouch said:


> Both Mirtrazapine and Nortriptyline can work here since they actually have a "blocking" antagoinst effect on some Serotonin receptors...
> 
> mirtazapine also usually increase "hunger"... So it would probable be like hitting 3 flyes at one strike, with adding some 7.5-15mg mirtazapin towards night!


Indeed, and Mirtazapine is prescribed in Germany very often, so it shouldn't be a problem to get it on doctor's prescription.
We do have Nortriptyline in Germany, but it is unknown to most docs and has a niche role.

I think I will propose Mirtazapine to my doc. Augmenting Sertraline with Mirtazapine might be a good combo.
As far as I know, it is even classified as a heroic combo by Stephen Stahl 

http://www.mind-and-brain-blog.de/en/576/drug-prescription-report-2012-antidepressants/


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## watertouch (Nov 4, 2013)

Duckbruck said:


> > Are there other receptors / transporters, that are affected only at higher doses?
> > Or why do people take it up to 100mg, 150mg or even 200mg? I've even heard of 300mg and 400mg :um
> 
> 
> ...


*Yes Stahl seems to use Mirtazapine as augmentation to allmost all medicines!!! :grin2:*


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## UltraShy (Nov 8, 2003)

imwiththedj said:


> As a doctor, I'd like to be creative...
> 
> Lexapro + Respidal,
> 
> ...


So what is at all creative about those?:stu

Anti-orgasm pill + atypical antipsychotic is all the rage today, designed for sheep who know how to follow a herd.

How about we give them an MAOI + benzo and a real chance at a better life? Yeah, I know that would be a wild a crazy idea.


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## Hordak (May 5, 2017)

watertouch said:


> *Yes Stahl seems to use Mirtazapine as augmentation to allmost all medicines!!! :grin2:*


Indeed :grin2:

And he also likes venlafaxine very much ^^


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## watertouch (Nov 4, 2013)

Duckbruck said:


> Indeed :grin2:
> 
> And he also likes venlafaxine very much ^^


venlafaxine introduced by Wyeth, now marketed by Pfizer, mirtazapine - Organon

In the book Stahl's essential psychopharmacology 3rd ed
Individual Disclosure Statements for Stahl mentions Wyeth, Pfizer, Organon and a couple more...



> Dr. Stahl has been a consultant, board member, or on the speakers bureau for the following pharmaceutical companies within the last three years: Acadia, Alkermes, Amylin,
> Asahi Kasei, Astra Zeneca, Avera, Azur, Biovail, Boehringer Ingelheim, BristolMyers Squibb, Cephalon, CSC Pharmaceuticals, Cyberonics, Cypress Bioscience, Dainippon, Eli Lilly, Forest, GlaxoSmithKline, Janssen, Jazz Pharmaceuticals, Labopharm, Lundbeck, Neurocrine Biosciences, NeuroMolecular, Neuronetics, Novartis, *Organon*, Pamlab, *Pfizer*, Pierre Fabre, sanofi-aventis, Schering-Plough, Sepracor, Shire, SK Corporation, Solvay,Somaxon, Takeda, Tethys, Tetragenbc, Vanda Pharmaceuticals, and *Wyeth*.


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## Hordak (May 5, 2017)

:O:grin2:


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## watertouch (Nov 4, 2013)

Duckbruck said:


> http://www.mind-and-brain-blog.de/en/576/drug-prescription-report-2012-antidepressants/


Nice link!
"Professor in experimental Neuropsychiatry"... 
I clicked on the "my publications". To see if he had published anything interesting... :O


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## Hordak (May 5, 2017)

watertouch said:


> Nice link!
> "Professor in experimental Neuropsychiatry"...
> *I clicked on the "my publications". To see if he had published anything interesting... :O*


And what is your conclusion? 

I've just posted it because of the prescription numbers ^^


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## watertouch (Nov 4, 2013)

Duckbruck said:


> And what is your conclusion?
> 
> I've just posted it because of the prescription numbers ^^


Im just gonna take a guess he that he likes venlafaxine and mirtazapin :grin2:

Some of his articles are interesting, but to me it will have verry little practical application.


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## zeusko87 (Sep 30, 2014)

UltraShy said:


> So what is at all creative about those?:stu
> 
> Anti-orgasm pill + atypical antipsychotic is all the rage today, designed for sheep who know how to follow a herd.
> 
> How about we give them an MAOI + benzo and a real chance at a better life? Yeah, I know that would be a wild a crazy idea.


haha

i just love your post :grin2:


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## Gillman fan (Sep 24, 2016)

I am going to humbly submit my cocktail, as per my sig, as an ultimate medication combo.
GOOD LUCK getting a doctor to prescribe all these meds.


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