WELLBUTRIN SR and XL (Bupropion)

Wellbutrin SR comes in two strengths: 100mg blue tablets and 150mg purple tablets. Wellbutrin XL comes in 150mg and 300mg tablets.

Wellbutrin enhances the brain’s natural stimulants, dopamine and norepinephrine. These help increase mental energy and motivation/interest. Wellbutrin also helps to control addictions, increase sexual functioning (especially libido and orgasm), and aids in weight reduction.  Wellbutrin works just as effectively as the Serotonin Reuptake Inhibitors (SSRI’S) for anxiety symptoms associated with depression. 

HOW TO TAKE FOR DEPRESSION

WELLBUTRIN XL

Do not break tablets.

WELLBUTRIN SR

OTHER TREATMENTS

SMOKING

300mg of Wellbutrin SR is usually the most effective dose to help quit or decrease smoking. It’s is even more effective when combined with nicotine replacement. (Nicotrol inhaler is best-tolerated form) 

A smoker does not have to be motivated to decrease or discontinue smoking. They just need to try the drug along with the smoking. Most people find that after taking the medication they no longer crave nicotine, and the need to smoke decreases.

SEXUAL DYSFUNCTION

Wellbutrin is effective for treatment of low sexual interest. It can also help primary orgasmic dysfunction or secondary orgasmic problems caused by other medications, especially SSRI’s. Treatment success is usually 40-50% for orgasmic dysfunction on an “as needed” basis.

WEIGHT REDUCTION

Wellbutrin has recently been found in studies to improve weight loss in obese patients. It is also an effective treatment for sluggishness and weight gain secondary to medications.

ADD and BOREDOM

Often respond well to Wellbutrin.

ANTIDEPRESSANT AUGMENTATION

Wellbutrin works well as a complementary drug with other antidepressants to achieve a more effective response in some patients.

SIDE EFFECTS

Side effects are usually mild and controllable with a dose adjustment or by adding a second medication to control side effects until they subside.

Most common side effects are:

• Insomnia
• Dry Mouth
• Nervousness
• Irritability

For full information, see package insert or prescribing information.

EFFEXOR XR (Venlafaxine)

EFFEXOR XR (Venlafaxine) is a slow release capsule and comes in 37.5, 75, and 150mg sizes.  It is a broad spectrum medication, which means it works by blocking reuptake of Serotonin (at 37.5 to 75mg) and norepinephrine (at 150mg+). Serotonin and norephinephrine are the two primary stress neuromodulators. Because Effexor XR works on both these neuromodulators, it is effective in treating anxiety and depression. When Effexor XR is taken, the brain levels of Serotonin and Norepinephrine are lowered if too high (as in anxiety), or raised if too low (as in depression).

Effexor XR has no significant drug/drug interactions and does not require dose decreases for the elderly.

HOW TO TAKE FOR ANXIETY/DEPRESSION

PARTIAL DOSING

During transition, (if less than 37.5 or between 37.5 and 75mg is needed), capsules may be opened and used as a sprinkle form on any soft food. Sprinkled granules remain slow release unless bitten into.

PANIC PATIENTS NOTE: 

This step is especially important in panic disorder where initial doses as small as 9mg may be needed. It is essential to minimize side effects with panic patients because of extreme sensitivity to side effects. The dose can usually be gradually increased.

DO NOT abruptly stop the medication.  This can cause rebound symptoms such as muscle aches and nausea. When tapering the dose decrease by 37.5mg every 3 days. 

WHAT IS THE BEST DOSE TO TAKE FOR ME?

Take enough, not too much!  How much is that?  I don’t know.  Each person has to find the dose for him/her that achieves the goal of remission (completely back to normal functioning).

• If you have some side effects but they are mild – remain on dose schedule
• If side effects are bothering you - shift the dose time, split the dose or decrease the dose for 3-4 days, then try to go back up
• If you have taken it for 1-2 weeks and not seeing significant benefit - increase the dose

SIDE EFFECTS

HOW DO I SWITCH FROM ANOTHER ANTIDEPRESSANT TO EFFEXOR XR?

Note: The most important rule of changeover is make only ONE change at a time. In other words don’t change the Effexor XR dose and SSRI dose both on the same day.

SONATA (Zaleplon)

One of my slogans is “The right medication at the right dose.”   When starting someone on a medication, I tell them I’m not looking for them to say, “Doctor I think it is helping some.”

What I’m looking for is “This medication is great! It has made my life better and it’s not causing any significant side effects.”

Essential to finding the right medication is knowing HOW TO TAKE your meds.  You need to take enough, but not too much! How much is that?  I don’t know.  Each person has to find the dose for him/her that achieves the goal of remission.  Remission = completely back to normal functioning.  Before you decide a certain medication "doesn’t work" or "makes me sick," make sure you’re taking the right dose at the right time and in the right way.

I will regularly add "How to take …" to this category.  Use the comment section below to tell us medications you would like a "How to take…" for.

Question: I have mitral valve prolapse syndrome(dysautonomia) and very infrequently get panic attacks from a food, smell, etc. For a one shot attack which is better at stopping it quicker, Xanax, Niravam or Klonopin?

– R.F.

Answer: When you say “mitral valve prolapse syndrome (dysautonomia),” I assume you are referring to the functional mitral valve prolapse associated with excessive adrenaline/noradrenaline that is assocaiated with panic attacks and anxiety caused by panic attacks. This type of M.V.P. usually goes away when panic attacks are adequately treated.
Your report of panic attacks brought on by a food smell is unusual. Through classical (pavlovian) conditioning, any stimulus, external or internal, can induce a physiological response (e.g. panic attack). Klonopin wafers dissolved sublingually (under the tongue) and Niravam, which is dissolved immediately on the tongue, are both reported to work faster. This is also true for Xanax (brand is better) but it’s very bitter and brand Ativan.
Some people do better with one, some do better with another. Because we have samples/coupons for Niravam and Klonopin wafers, those are the ones I now give patients to compare. Most people do well with at least one of these. Some do well with either. I don’t think there’s any way to predict which will be better for any individual. I usually start with Klonopin if there are also racing thoughts or obsessing. I start with Niravam if there are problems with depression.
Niravam (or Xanax) is out of the system much quicker (mostly by 6-8 hrs.), whereas Klonopin takes much longer to clear (up to 24 hours or more). Some people prefer the shorter duration, others like the longer duration. Of course, nothing is simple - there are people who prefer one under certain conditions and the other one under different conditions.
Finally, you have to take “enough, not too much” (i.e., the right dose).
Good luck!
Dr. Jones

FAQs: Comparing Meds

Question: How quickly does Cymbalta start working - relative to other antidepressants?

– M.F.

Answer: Some effects of Cymbalta may start within the 1st 2-3 days (it especially helps with chronic pain and possibly insomnia or anxiety). The antidepressant effects and most of the anti-anxiety effects usually take 2 weeks to begin. Typically this is 2 weeks from the time you start an effective dose (30-60 mg in most people, but occasionally 60-120 mg per day).
For antidepressants, the rate of onset of benefit seems to indirectly correlate with protein binding (i.e., the lower the binding, the higher the percent that crosses the blood-brain barrier). On this basis the relative order of speed of onset from quickest to slowest is Effexor, Lexapro, Wellbutrin & Celexa, Cymbalta, Paxil & Prozac, and Zoloft.
Faster rate of onset can also be associated with increased risk for side-effects in the 1st 2-3 days, but most of these dimminish or go away within the 2 weeks.

FAQs: How Meds Work

Does treatment of ADHD with stimulants increase the risk of substance abuse?
This question has been extensively researched by Dr. Wilens and Dr. Biederman at Harvard Medical School Department of Psychiatry. There were two significant findings.
First - Untreated ADHD doubles the risk of alcohol and/or recreational drug abuse.
Second - Treatment of ADHD with stimulants cuts the risk in half, equal to the general population.
As with other measures of functioning medical treatment of ADHD doesn’t eliminate problems but levels the playing field. FAQ’s ADHD

It’s frustrating trying to figure out what happened in the Miami airport this Wednesday. For the first time in U.S. history, a passenger was gunned down on the jetway after he abruptly left the plane just before takeoff.

At first it seemed tragically clear cut. He had Bipolar disorder, was off his meds, and he said he had a bomb. He apparently refused to comply when the air marshals ordered him to the ground. He then reached into his backpack and the air marshals had no other option than to shoot.

Questions like couldn’t they have just wounded him or physically subdued him or used a taser gun have been fairly well answered as too risky, not safe enough or not decisive enough. The marshals did what they were trained to do.

So why isn’t that the end of the story? In today’s USA Today, it was reported that after having initially taken his seat on the plane next to his wife, he suddenly jumped up and ran down the aisle flailing his arms. A flight attendant reportedly told him he couldn’t get off the plane - to which he said, "I have a bomb." But also on today’s AP wire, two passengers close to the exchange between him and the flight attendant said emphatically they never heard the word bomb.

Did someone misunderstand what he was saying? His wife was running up the aisle saying he’s Bipolar and off his meds, although one passenger reported that the wife was speaking Spanish, saying, "He’s sick. He has a problem."

Why did he feel he had to get off the plane? The most common explanation would be that he was having a panic attack - very common in individuals with Bipolar disorder. 

Unfortunately, I have not been able to find any information from the wife about what he was saying. There are reports today that in the airport, before boarding the plane, he seemed agitated and was singing "Go Down Moses" as his wife tried to calm him. It was also reported by a passenger near him on the plane that he seemed very restless and suddenly said he had to get off.

Bipolar disorder, when not controlled, can lead to a feeling of agitation that makes it very difficult to sit still. It can also produce delusional ideas or hallucinations that direct a person to flee.

Adding to the tragedy and confusion are several reports about what a nice, gentle person he was. He was well liked at work and in his Orlando neighborhood. He and his wife had been married over 18 years and had just returned from a missionary trip to Ecuador where Mr. Alpizar had served as a translator for a group of dentists and ophthalmologists offering their services to poor communities.

Assuming he did say he had a bomb - what would have been his motivation? Was he using that as a threat so they would let him off the plane? We obviously need more information. But mostly, we can’t just say - "He was Bipolar and that explains his crazy behavior."

Why was he allowed to board the plane in the first place? Why didn’t his wife talk to someone and try to get help for him instead of boarding the plane? Hopefully, we’ll get some answers soon. I’m eager to hear your opinions on this story.

We received an email recently about a patient who was suffering from significant distress and got nothing but the run-around from her doctors. She had undergone extensive testing but was not given any clear feedback or results, and was basically let go with no explanation or significant treatment. Her son was very distressed and wondered, "What’s wrong with the system?"

My staffs’ response was, "We hear stories like that on the phone every day." Recently, I was lying in bed, feeling under the weather, and I had this flash - "What if I really got sick?" I suddenly felt the need to say to my wife, "If I’m ever unconscious, and you can’t wake me up, don’t call an ambulance. I would rather take my chances here."

On more than one occasion, I have said to a patient who was sick, “I don’t know any doctors in your area. You’re safer staying home than seeing a doctor at random.” The number of horror stories and irrational medical treatment that I have heard is staggering. While medical science is growing exponentially, satisfaction with medical care seems to be on the decline. What is going on?

There are undoubtedly many factors contributing to the problem. When I first started treating patients in the 60’s, patients presented with symptoms, and doctors did whatever tests they thought were necessary. Once a diagnosis was established, treatment options were discussed and the best treatment for that patient would be initiated. Follow-up would be determined according to each patient’s needs and treatment response. The insurance would cover whatever cost they were contractually obligated to cover.

Over time medical costs grew and insurance companies began to balk. A monitoring system was established as a new entity that would regulate medical care (aka “managed care” but really “managed cost”). They would take 20-25% of the medical dollars available, and in return, cut cost to both insurance companies and employers. Meanwhile, the employee/insured had 30% or more taken away from them in medical reimbursements and coverage.

Insurance 101: Did you know that there are people in this country today who believe insurance companies exist to help you? They exist to make money. They make the most money by collecting as much as possible in premiums and paying out as little as possible in claims. Insurance companies now have the most power. “The tail wags the dog.” Of course, they make a lot of money and contribute generously to politicians. It’s the “golden rule” – “Him with the gold is him who makes the rules.”

A case in point – I evaluated a young woman who ironically worked for a large insurance company. She was severely depressed and although not needing hospitalization, needed a lot of therapy along with antidepressant medication. Her insurance only covered “approved therapists” on their list. I said fine but I would like to see the list so I could suggest a therapist that I had a relationship with so we could coordinate her care. They would not share the list. They informed me that therapists were selected who had more of a short-term therapy approach. How was this established? Well, how many times would a patient go back to see them … if they saw them only once – that would be the most effective therapist. If the went back 12 or more times, they obviously were not short-term oriented and would be presumably dropped off the list. You get the picture.

How does this impact the treatment of a given patient by a given doctor? Most doctors who do procedures that can be very costly have to deal with insurance companies. Myself and other psychiatrists and few other doctors have opted out of insurance plans because medical care of patients is often adversely affected by restrictions in time, frequency, type of appointments, etc. I still have to deal with insurance companies at times to get prescriptions approved, and that can be a nightmare. Recently, I had a patient who had excessive daytime sedation and was in jeopardy of being fired. The only medication that worked for her was Provigil. She couldn’t afford it. The insurance company refused to cover it despite the strong letters of appeal.

Insurance companies may be quick to pay $1000’s for highly technical procedures but won’t pay for 15 minutes for a doctor to counsel a patient about weight, smoking, etc. They frequently won’t pay a primary care doctor for services related to treating anxiety, depression, and insomnia even though they provide the bulk of this treatment.

One of the most harmful consequences of this shift to insurance company domination is that by gradually reducing what they pay physicians, physicians gradually decrease the amount of time they spend with patients. Medical office overhead is very high, and doctors have to generate a lot of cash flow to cover all expenses. I’m not talking about super-specialists with very expensive surgeries or procedures – they’re doing fine.

Recently I was speaking in a primary care clinic, and I asked a doctor how he evaluated for depression. He said, “I used to have them fill out a check list of symptoms for depression, but now I don’t have time. I just note whether they’re tearful or look depressed.” Unfortunately, only 70% of people who are clinically depressed report feeling sad, down, or depressed. 30% have other symptoms, especially loss of interest, motivation, or pleasure (85-90% of depressed patients). I guess they’re out of luck.

Doctors don’t have enough time to adequately evaluate or counsel a patient. Insurance companies usually won’t pay for a clinical assistant to help. The system is broke! I’m not sure what the solution is, but I’m sure it’s not the government.

People have to take more individual responsibility to research their symptoms, diagnoses and treatments. They have to network and do everything possible to find a physician who takes the time to listen and address their concerns and then provides either adequate care or refers them to someone else.

All fields of medicine are going to get increasingly complicated and expensive. I’m afraid things are going to get worse before the pendulum begins to swing back.